Urogynaecology Flashcards
1
Q
In POP-Q: define Aa
A
On anterior vaginal wall. Located in midline, 3 cm proximal (-3 in absence of prolapse) to the external urethral meatus. Corresponds approximately to external urethral crease. Range of movement will be -3 to +3.
2
Q
In POP-Q: define Ba
A
On anterior vaginal wall. Most distal position of any part of the upper anterior vaginal wall between point Aa and the anterior vaginal fornix (or vaginal vault after hysterectomy).
3
Q
In POP-Q: define C
A
Superior vagina. Most distal edge of cervix or leading edge of vaginal vault after hysterectomy.
4
Q
In POP-Q: define D
A
Superior vagina. Posterior fornix or pouch of Douglas in a woman who still has a cervix. Represents attachment of uterosacral ligaments to the cervix. Its measurements allows differentiating suspensory failure of the uterosacral ligaments from cervical elongation.
5
Q
In POP-Q: Ap
A
Posterior vaginal wall. Located in midline 3 cm proximal to hymen (-3 in absence of prolapse). Its range of movement will be -3 to +3.
6
Q
In POP-Q: Bp
A
Posterior vaginal wall. Most distal position of any part of upper posterior vaginal wall between point D (or vaginal vault after hysterectomy) and point Ap.
7
Q
In POP-Q: gh
A
Measured from middle of external urethral meatus to posterior midline hymen (or the firm tissue of the perineal body if hymen distorted by scarring).
8
Q
In POP-Q: pb
A
Measured from posterior margin of the gh to the midanal opening.
9
Q
In POP-Q: tvl
A
Greatest depth of vagina when point C or D is reduced to its normal position
10
Q
In POP-Q: define stage I POP
A
Leading edge of prolapse not lower than 1 cm above the hymen.
11
Q
In POP-Q: define stage II POP
A
Leading edge of prolapse is between -1 and +1 cm in relation to the hymen.
12
Q
In POP-Q: define stage III POP
A
Leading edge of prolapse is 1 cm beyond the hymen but without complete eversion
13
Q
In POP-Q: define stage IV POP
A
Complete vaginal eversion.
14
Q
List the risk factors for vesico-vaginal fistula:
A
○ Hysterectomy (usually supratrigonal and medial to both ureters). Intraoperative risk factors: uterus weight >250g; long operation time; concurrent ureteral injury.
○ Obstructed labour (2% in developing world)
○ Obstetric: instrumental delivery, manual removal of placenta; Caesarean section, peripartum hysterectomy, uterine rupture at term.
○ Pelvic mesh erosion
○ Radiation therapy
○ Inflammation: PID, diverticulitis, IBD.
15
Q
Describe how you would diagnose a vesico-vaginal fistula:
A
○ Pelvic examination: Recently formed fistulas may appear as a small, red area of granulation tissue with no visible opening, or an actual hole may be seen.
○ Dye test: Insert bladder catheter and create urethral seal with gauze to prevent bypass leaking.
Insert tampon or vaginal pack into vagina.
Instil bladder with saline mixed with methylene blue dye gradually (60 mL/min).
Check if blue dye has stained tampon/vaginal pack.
If no leakage is seen, ask patient to cough or perform Valsalva manoeuvre.
○ Examination under anaesthesia + dye test.
16
Q
List your differential diagnoses for a suspect vesico-vaginal fistula:
A
Pelvic collection / seroma; urinary retention with overflow incontinence; SUI; UTI
17
Q
List the management options for a vesico-vaginal fistula:
A
○ Latzko procedure: surgical closure of the fistula via the vagina.
○ Mackenrodt procedure: vaginal approach, especially for high vaginal fistulas. Tissue graft used (Martius/labial fibrofatty; gracilis muscle peritoneum) to reinforce repair.
○ Abdominal approach surgical repair: fistula is excised and bladder and vagina closed. Omental tissue is interposed between the bladder and vagina to separate the suture lines and act as a neovascular pedicle.
○ Post-repair cares: IDC should be left in for 7-14 days Referral to urologist. Cystogram prior to removal of IDC
18
Q
What is the incidence of POP?
What % will undergo surgery for POP or continence?
A
204 per 1000 woman years
11-19% will undergo surgery.
19
Q
What percentage of women who undergo surgery for POP will need re-operation?
A
30%
20
Q
List risk factors for POP:
A
○ Age
○ Parity and vaginal delivery: 4 x increase risk after one child, 11 x increase risk after four or more children delivered vaginally.
○ Postmenopausal oestrogen deficiency.
○ Obesity and chronic increase in intra-abdominal pressure.
○ Neurological: spina bifida, muscular dystrophy.
○ Genetic connective tissue disorders: Marfans, Ehlers-Danlos syndrome.
○ Hysterectomy
21
Q
Describe the three levels of support for the vagina:
A
Level I: vertical suspension by the uterosacral and cardinal ligaments.
Level II: lateral attaches of the middle third of the vagina to the paracolpium and paravagina; these connect to the ATFP which in turn connects to the levator ani muscles.
Level III: lower third is supported by fusion of vaginal endopelvic fascia to the perineal body, levator ani and urethra.
22
Q
What provides somatic innervation to the pelvic floor?
A
Pudendal nerve (nerve roots S2-S4)
23
Q
What provides autonomic innervation to the pelvic organs?
A
Inferior hypogastric plexus
24
Q
Describe the steps you would take in a physical exam for a woman with POP:
A
- Abdominal examination: ?masses.
- Vaginal and speculum examination:
- Look for central compartment prolapse.
- Isolate the anterior and posterior walls and look for anterior and posterior wall prolapse.
- Assess maximum descent of prolapse.
- Modified Oxford score for pelvic muscle contraction (0-5)
- Cough test for UI with support / replacement of POP.
25
What percentage of POP is anterior vaginal wall prolapse?
50%
26
Posterior vaginal wall prolapse may develop after which urogynaecological procedure and why?
After Burch colposuspension due to change in vaginal axis.
27
What is a major risk factor for posterior vaginal wall prolapse and what structural supports may have been interrupted to cause this?
Vaginal and perineal tears, poor episiotomy repair.
Rectovaginal septum (vaginal apex to perineal body) and pararectal fascia.
28
Describe your management options for uterine prolapse:
1. Vaginal hysterectomy
2. Abdominal sacrohysteropexy
3. Sacrospinous fixation
4. (Total vagina mesh) - fertility sparing.
5. LeFort's colpocleisis - fragile elderly, not wanting to have sex again.
Pessary if doesn't want surgery, wants to delay surgery or too frail for surgery.
29
Briefly describe the vaginal hysterectomy procedure:
Vaginal approach. Circumferential vaginal incision around cervix. Enter peritoneum. Identify uterosacral ligaments. Separate bladder from vaginal tissue to create vesicouterine space. Cardinal ligament pedicles. Uterine artery pedicles. Deliver uterus downwards to identify utero-ovarian ligaments, round ligaments and fallopian tubes. Perform ligation as indicated (i.e. ovarian conservation vs. BSO). Deliver pelvic organs. Check haemostasis. Closure.
30
Describe your management options for anterior vaginal prolapse:
What % of anterior compartment prolapse will have recurrent prolapse following surgery?
What complications are associated with these procedures?
1. Anterior colporrhaphy.
2. Paravaginal repair
3. (Mesh repair).
Recurrence rate up to 40%.
Complications:
- Injury to bladder, ureters, urethra, genitofemoral or ilioinguinal nerves (0.5-2%)
- Urinary: retention, recurrent UTIs, de novo SUI or UUI
- Enterocoele
- Erosion of mesh or suture material
- Dyspareunia (less common c.f. posterior repairs)
31
Describe your management options for posterior vaginal prolapse:
What are the complications associated with these procedures?
1. Posterior colporrhaphy
2. Site specific fascial defect repair
3. Vaginal enterocoele repair
Complications:
- Rectal injury
- Dyspareunia
- Vaginal shortening
- Pundendal neuralgia
- Worsening bowel symptoms
32
Describe your management options for vault prolapse:
1. Abdominal sacrocolpopexy
2. SSF
3. Colpoclesis
33
Describe the indication for abdominal sacrocolpopexy, success rate and complications:
Indication: vaginal vault prolapse.
Success rate: 90-98%
Complications: bleeding, rectal trauma, ileus, mesh erosion, occult SUI, sacral osteomyelitis.
34
Describe the indication(s) for sacrospinous fixation, success rate and complications:
Indications: vaginal vault prolapse; uterine prolapse.
Success rate: >90%
Complications: pudendal neurovascular injury; buttock pain; anterior vaginal wall prolapse development; sexual dysfunction.
35
Justify the reasons (as per RANZCOG statement) on why mesh should not be a first line treatment for anterior vaginal prolapse treatment:
- Risk of mesh erosion 8-15%
- Increased risk of re-operation for prolapse, urinary incontinence and mesh exposure.
- High rates of bladder injury, SUI and prolapse in other vaginal sites.
36
When might you, if any, consider vagina mesh implants for treatment of anterior vaginal prolapse?
If woman is at high risk of recurrence i.e. obesity, young age, increased intra-abdominal pressure (asthma, chronic cough), stage 3-4 prolapse.
37
Outline how you would counsel a woman with anterior vaginal prolapse regarding mesh repair:
- Very little robust data on efficacy and safety of TV mesh products
- Mesh is not indicated for asymptomatic POP; there is limited long term data on outcomes for untreated asymptomatic POP
- Explain that it is considered a permanent procedure and that it may not be possible to completely remove mesh.
- Potential complications: mesh erosion / exposure; reoperation; dyspareunia; vaginal scarring/stricture; fistul aformation; unprovoked pelvic pain at rest.
- Alternatives to surgery: PFMT, vaginal pessaries.
- Alternative surgeries: anterior colporraphy, abdominal sacrocolpopexy.
- If mesh issues arise, issues may not complete resolve with removal of mesh.
38
List symptoms a patient may present with that may indicate a mesh complication:
- Pain in back, abdo, vagina, pelvis, leg, groin or perineum.
- Fistula
- Abnormal vaginal discharge or bleeding
- Dyspareunia; pain or injury in partner.
- Bowels: difficulty or pain on defaecation, faecal incontinence, rectal bleeding or passage of mucus
- Infection
39
List your initial management of of a small <1 cm squared vaginal mesh erosion:
- Postmenopausal women: 3 month trial of topical vaginal oestrogen cream.
- Treat any concomitant infections with antibiotics.
- Consider partial or complete mesh removal if persisting symptoms.
40
List the indications for urodynamic studies:
- Mixed urinary incontinence where type is unclear.
- MUI that is urge predominant.
- Anterior or apical prolapse
- Suspected voiding dysfunction
- Previous surgery for SUI.
41
Describe what is uroflowmetry and the main variables it measures:
Uroflowmetry measure the flow rate of urine over time. It diagnoses voiding difficulties. Woman sits on a commode and voids into a funnel that measures flow rate.
Variables measured: average and maximum flow rate; total volume voided; flow time; flow curve pattern.
42
What might a urine flow rate of >40 mL/sec indicate?
Low outlet resistance and SUI.
43
What might a urine flow rate of <15 mL/sec indicate?
Outlet obstruction.
44
What is a normal flow curve pattern? How might obstructed flow manifest on this curve?
Normal flow curve pattern is bell-shaped.
Obstructed flow may manifest with interruptions or plateaus in the curve.
45
Describe what is cystometry and the main variables it measures:
Cystometry assesses the relationship between pressure and volume in the bladder during filling and voiding.
Variables measured: intra-abdominal pressure, bladder pressure (detrusor pressure calculated from Pabdo and Pvesic); volume of urine leakage; residual volume; peak flow rate; volume at first and maximal desire to void.
46
What tests can be performed during cystometry?
- Cough provocation test - for SUI
- Running water provocation test - for OAB
- Leak point pressure (abdominal and detrusor)
47
What is the definition of overactive bladder syndrome?
Urgency, with or without UUI, usually with frequency and nocturnal
OAB wet - with UUI
OAB dry - no incontinence
48
What is the definition of detrusor overactivity?
Urodynamic observation
| Involuntary detrusor contractions during the filling phase of cystometry that may be spontaneous or provoked
49
What is urodynamic stress urinary incontinence?
Cystometric demonstration
| Leakage of urine during increased abdominal pressure in the absence of detrusor contraction during filling cystometry
50
What is a normal PVR?
<50mL
51
At what volume (of bladder filling) is it normal to have the first desire to void?
150-200mL
52
What are the side effects of antimuscurinic drugs?
```
Dry mouth
Blurred vision
Tachycardia
Drowsiness
Constipation
CNS: Disorientation, hallucinations, convulsions, cognitive impairment
```
53
What medication helps nocturnal polyuria?
Desmopression: synthetic analogue of vasopressin
| If used at night, inhibits diueresis
54
What is the first line management for UUI and MUI?
Bladder drill or re-training
Aims to
- increase the intervals between voids
- increase bladder capacity
- reduce the number of UUI episodes
55
What is the first line management for SUI and MUI?
Pelvic Floor Muscle Training
56
What is the gold standard surgical management of SUI?
MUS / TVT
Superseded Burch Colosuspension
57
What are the two main surgical management options for UUI?
Percutaneous sacral nerve root stimulation
- chronic electrical stimulation of the S3 roots
- result in inhibition of the sacral bladder reflex
Botox
- injected into the detrusor muscle using cystoscope
- inhibits ACh release at the presynaptic Cholinergic junction, inhibiting neurotransmitter release
58
What nerve innervates the urethral sphincter?
Pudendal nerve (S2-4)
59
What was the conclusion of the Cochrane review looking at Anticholinergics vs non-drug active therapies for OAB syndrome in adults?
Anticholingerics are associated with good symptomatic improvement
60
What were the findings of the Cochrane Review looking at Botulinum toxin injections into the bladder for overactive bladder?
Overall Botox appears to be effective therapy for refractory overactive bladder symptoms
61
What is the 5 year success rate of Mid-urethral sling operations for SUI, as per the Cochrane Review?
80%
| Irrespective of type / route
62
What is the risk of tape erosion with Mid Urethral sling operations for SUI, as per the Cochrane Review?
2%
63
What were the key findings of the Jan 2020 Cochrane Review looking at traditional suburethral sling operations for UI?
Surgery works better than medication for treating UI
Traditional slings are associated with less leakage than colposuspension, and with less re-operation
Traditional slings vs tape - insufficient evidence
64
What is the success rate of open retropubic colposuspension for UI, as per the Cochrane Review?
At 1 year and 5 years
1 year = 85-90%
5 years = 70%
Effective technique for SUI and MUI
65
What were the key findings of the Cochrane Review looking at the laparoscopic approach for UI?
(Dec 2019)
```
High quality evidence
Lap colposuspension with sutures is AS EFFECTIVE as open colposuspension for curing UI in the short term.
Uncertain re
- complications
- Long term outcomes
```
MUS may be associated with fewer re-operations than Lap colposuspension
66
Describe the pathophysiology that contributes to anterior vaginal wall prolapse:
- Loss of pubocervical fascia support.
- Loss of posterior pubourethral ligament support; particularly maintains bladder neck elevation and contributes to continence.
67
What % of patients with vaginal vault prolapse have occult SUI?
Up to 50%.
Should assess bladder function with prolapse reduced (prolapse reduction test) prior to surgery.
68
Regarding anterior and central compartment prolapse:
What are the indications for conservative management or mechanical devices?
What does conservative management involve?
Indications:
- Mild-moderate prolapse
- Incomplete family
- Frailty
- Wanting to avoid or delay surgery.
Conservative management (evidence of benefit is poor):
- Lifestyle changes
- Pelvic floor muscle training
No RCT evidence pessaries are effective.
69
Regarding pessaries:
What are benefits?
What are the risks/disadvantages?
Benefits:
- Avoids surgery / anaesthetic. Good for frail patients.
Risks/disadvantages:
- Increased vaginal discharge
- Difficulties removing
- Interfere with sexual intercourse
- Erosions and fistulas
- Formation of fibrous bands attaching pessary to vagina
70
Describe the mechanisms needed to maintain continence:
Low intravesical pressure:
- Hydrostatic pressure in bladder (small).
- Transmission of intraabdominal pressure: particularly to urethra.
- Tension in bladder wall: controlled by detrusor.
Urethral function:
- Watertight seal: submucuous rich venous supply and urethral secretions.
- Intrinsic and extrinsic muscles: at rest maintained by constant extrinsic and intrinsic muscle contraction; extrinsic muscles of pelvic floor contract when intra-abdo pressure increases to maintain urethral closure.
- Urethral support: pubocervical fascia (between urethra and anterior vaginal wall) and anterior and posterior pubourethral ligaments connecting urethra to pubic bone.
71
Describe the mechanism of bladder voiding:
Neurological inputs:
- Voluntary control: pontine reticular formation centre in cerebellum.
- Detrusor: sacral spinal reflex.
- Urethral function: pudendal nerve.
Storage:
- Bladder fills and sensory receptors in wall send impulses via pelvic splanchnic nerves to sacral nerve roots S2-4 --> lateral spinothalamic tract.
- Descending impulses inhibit detrusor contraction. Alpha adrenergic receptors increase urethral outlet resistance. Beta adrenergic receptors cause detrusor smooth muscle relaxation.
- Voluntary pelvic floor muscle contraction aids urethral closure.
Initiation:
- Relaxation of pelvic floor and extrinsic and instrinsic striated mucle.
- Suppression of descending inhibitory impulses --> detrusor contraction.
- Parasympathetic inhibition of resting tone of urethral smooth muscle --> relaxation.
- Parasympathetic stimulation S2-4 via hypogastric nerve --> M2 and M3 muscarinic receptor activation in bladder --> detrusor contraction
Voiding:
- Commences when intravesical pressure > urethral pressure.
- As intravesical pressure falls, the pelvic floor and urethral muscles contract, causing urethral closure and interruption of flow, completing cycle.
72
SUI results from the failure of:
Lack of bladder neck support:
- damaged pubourethral ligament)
Poor urethral closure:
- Striated or smooth muscle sphincter function
- Mucosa seal function
- Pudendal innervation
73
What % of urinary incontinence is SUI-related?
60-70%
74
# Define UUI:
What % of urinary incontinence is UUI-related?
Involuntary loss of urine associated with strong desire to void.
20-30%
75
List the aetiology of UUI:
- Detrusor overactivity: failure of cortical inhibition of sacral reflex arc
- Idiopathic: worse with caffeine, anxiety, cold
- Neurogenic (UMN lesion)
- Urethral obstruction following surgery
76
List medical conditions that can exacerbate urinary incontinence:
- Diabetes
- Cardiovascular disease
- Neurological: Parkinson, MS, stroke, spinal cord injury
- Renal
77
What drugs can exacerbate urgency?
- Diuretics
- Caffeine
- Lithium
78
What drugs can exacerbate stress incontinence?
- Alpha blockers (reduces bladder outlet resistance)
- ACEi, ARB
- Hormone replacement therapy
79
What drugs can impair bladder empyting?
- Anticholinergics
- Antidepressants (anticholinergic side effects)
- Alpha agonists (bladder neck contraction)
- Calcium channel blockers (reduce smooth muscle contractility of bladder)
80
What drugs can impair patient access to toileting?
- Benzodiazepines
| - Sedatives
81
Outline your neurological exam focussed for urinary continence issues:
- Knee and ankle deep tendon reflexes (S2-S4)
- Toe dorsiflexion and abduction (S3)
- Sensory innervation of sole and lateral aspect of foot (S1), posterior thigh (S2), perineum (S3) and perianal area (S4)
- Cognitive impairment if indicated by age >75 or otherwise.
82
List investigations for urinary continence work-up:
- Urine dipstick +/- MSU all women.
- Post-void residual: ideally with bladder scanner.
- Cystoscopy: persistent haematuria, recurrent UTISs, reduced bladder capacity on cystometry, bladder pain, suspected fistula.
- Urodynamics
- EMG: urethral sphincter function and pelvic floor musculature function.
83
What is your general advice to all women with urinary incontinence?
- Fluid restriction to 1-.15L/day
- Avoid tea, coffee and alcohol.
- Weight loss
- Dietary advice for constipation
- Smoking cessation
- Review drugs.
84
What are the management options (in order of recommended treatment) for SUI?
1st line: PFMT 3 month duration at least.
2nd line: surgical.
- Burch colposuspension
- TVT and autologous rectus fascial sling
- TOT
- Intramural bulking agent
- (Artificial urinary sphincters)
3rd line: duloxetine
85
Regarding open/Burch colposuspension for SUI:
What are the success rates at 1 and 7 years?
What are the benefits/advantages?
What are the disadvantages?
What are the complications?
Success rates:
- 1 year 85-90%
- 7 years 70%
Benefits/advantages:
- High success rate at 1 year
Disadvantages:
- May need further surgery for POP
Complications:
- Voiding difficulties 6%
- De novo detrusor overactivity 22%
- POP (mainly posterior wall) 30%
- Dyspareunia 3%
- Recurrent UTIs 5%
86
Regarding TVT for SUI:
What are the success rates at 1 and 7 years?
What are the benefits/advantages?
What are the disadvantages?
What are the complications?
Success rates:
- 1 year 85-90%
- 7 years 80% but erosion rate 1%
Benefits/advantages:
- Faster recovery and shorter hospital stay
- Can be done under local or regional anaesthesia.
Disadvantages:
- Bladder perforation more common than colposuspension.
Complications:
- Bladder perforation 4%
- Urethral perforation 0.5%
- Haematoma 1.5%
- Nerve injury 0.7%
- Voiding difficulties 11%
- Need for long-term ISC 1.8%
- De novo detrusor overactivity 6%
- Tap erosion 1.1%
- Need to trim tap or remove 1.2%
- Recurrent UTIs 7%
87
Regarding TOT for SUI:
What are the success rate at 1 year?
What are the benefits/advantages?
What are the disadvantages?
What are the complications?
Success rates:
- 1 year 85-90%, similar to TVT but long term data lacking.
Benefits/advantages:
- Significantly less bladder injury than TVT (0.5% vs 4%)
- Faster recovery and shorter hospital stay
- Can be done under local or regional anaesthesia.
```
Disadvantages:
• Bladder injury 0.5%
• Urethral injury 1%
• Voiding dysfunction 2%
• De novo urgency 4%
• Vaginal erosion 2.5%; vaginal perforation 0.7%
- Anecdotal: groin pain.
```
88
Regarding artificial urinary sphincter for SUI:
What are the success rate at 1 year?
What are the benefits/advantages?
What are the disadvantages?
What are the complications?
Success rates:
- 1 year 90%
Benefits/advantages:
- Highly effective
- Useful when previous surgery has failed.
Disadvantages:
- Expensive
```
Complications:
• Vaginal injury
• Bladder injury
• Urethral injury
• Infection
• Erosion
• Device malfunction
• Surgical device revision or removal.
```
89
Regarding duloxetine for treatment of SUI:
What class of drug is it?
What is its mode of action?
What is its side-effects?
What is the evidence for its use?
Class: SNRI
Mode of action: Acts at sacral spinal cord to increase pudendal nerve activity and increase urethral sphincter closure.
Side-effects: nausea, constipation, dry mouth, insomnia, somnolence, dizziness.
Evidence: short term RCT reduces incontinence episodes and improves QoL but clinical difference is small.
90
What are the management options (in order of recommended treatment) for UUI?
1st line: weight loss if BMI >30.
2nd line: bladder drill retraining
3rd line: medications including antimuscarinics, vasopression analogue and topical oestrogen.
4th line: surgical
91
Regarding bladder drill re-training for treatment of UUI:
Describe treatment and duration.
What are the benefits?
What are the disadvantages?
Method: timed voiding every hour if not desire to do so and not voiding if there is urgency. Gradually increasing voiding intervals until desired interval for 2-4 hours reached.
Duration: at least 6 weeks.
Benefits:
- Evidence of efficacy
- Avoids side-effects of medications.
Disadvantages:
- Reliant on patient compliance and motivation.
- Hight rate of relapse.
92
Regarding anti-muscarinic medications for treatment of UUI:
What medications are available?
How long does it take for an effect to be seen?
What are the side-effects?
Are there any contraindications?
Medications:
- Oxybutynin
- Tolterodine: fewer S/Es.
- Vesicare/solifenacin
Onset of action: 4 weeks.
Anti-muscarinic side-effects:
- Dry mouth
- Blurred vision
- Tachycardia
- Constipation
- Drowsiness
- CNS: disorientation, hallucinations, convulsions, cognitive impairment
Contraindications:
- High risk of falls/poor mobility
- Coexisting: poor bladder emptying, cognitive impairment, dementia
- Concurrent medications that add to total anticholinergic effect.
93
Regarding desmopressin for treatment of UUI:
What is its mode of action?
Mode of action: vasopressin analogue that inhibits diuresis while avoiding vasopressive effects.
Use at night especially for patients with nocturia.
Reduces urine output by 50%.
94
What surgical options are available for treatment of UUI?
1. Botulinum toxin type A bladder wall injection:
- Reduces contractility of detrusor muscle
2. Percutaneous sacral nerve stimulation:
- Modifies innervation of the detrusor muscle
3. Augmentation cystoplasty:
- Increases bladder capacity
4. Urinary diversion:
- bypasses lower uringary tract.
95
Regarding Botulinum toxin type A bladder wall injection for treatment of UUI:
What is the success rate?
What are the pros?
What are the cons?
What are the complications?
Success rate 50-75%
Pros:
- Can be done under local anaesthetic.
Cons:
- Needs repeat treatments
- Wears off with time; variable duration of effect.
Complications:
- Urinary retention and need to ISC.
- Recurrent UTIs
96
Regarding percutaneous sacral nerve stimulation for UUI:
```
When is it indicated?
What is the success rate?
What are the pros?
What are the cons?
What are the complications?
```
Indication: treatment resistant overactive bladder or not prepared to accept risk of void dysfunction with Botox.
Success rate 39-77%.
Pros:
- Efficacy sustained for 3-5 years.
Cons:
- Reoperation rate 30%
- Removal of device 7%
Complications:
- Infection
- Change in bowel function
- Movement of electrode
- Device malfunction and battery failure.
97
Regarding augmentation cystoplasty:
What is the success rate?
What are the cons?
What are the complications?
Success rate 50-90%
Cons:
- Electrolyte disturbance
- Mucus retention
- Recurrent UTIs
- Urinary retention
- Need for ISC.
- Risk of malignant transformation.
- Requires life long follow-up.
