Urogynaecology Flashcards
What is prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines. Female POP refers to the descent of the pelvic organs towards or through the vagina
Describe the pathophysiology of POP
Prolapse occurs due to progressive weakness of pelvic floor muscles and stretching of endopelvic fascia/ligaments, which usually supports viscera, so organs fall out of place
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethra only
What is a cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder
What is a uterovaginal prolapse?
This term is used to describe prolapse of the uterus, cervix and upper vagina
What is a enterocele?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
What is a rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging towards into the vagina
Give risk factors for POP
Pregnancy and vaginal birth
- Forceps
- Large baby
- Prolonged secondary stage
- Parity
Advancing age:Muscles and ligaments weaken
Obesity: Increased pressure on pelvic floor
Previous pelvic surgery: Heals with fibrous tissue which is weaker
Hormonal/Menopause
Quality of connective tissue
Constipation
Occupation with heavy lifting
Exercise
Anything that involves pushing on ligaments/endoplasmic fascia and muscles
Give vaginal symptoms of POP
Sensation of a bulge/protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
Difficulty in having sex
Give urinary symptoms of POP
Urinary incontinence
Frequency
Urgency
Weak or prolonged urinary stream
Manual reduction of prolapse to start or complete voiding
Give bowel symptoms of POP
Incontinence of flatus, liquid or solid stool
Feeling of incomplete emptying/straining
Urgency
Digital evacuation to complete defecation
Splinting or pushing on or around the vagina to start or complete defecation
What investigations can be used in POP diagnosis?
USS/MRI: Allow identification of fascial defects/measurement of levator ani thickness
Urodynamics: Concurrent urinary incontinence
IVU or renal USS: If suspect ureteric obstruction
Only do investigations if think there is associated conditions
What non surgical management is available for POP?
Pelvic floor muscle training: Mild prolapse, increase pelvic strength and bulk and relieve the tension on the ligaments
Perinometer: Measures strength of voluntary contractions
Biofeedback: Monitors if doing contraction right
Vaginal cones
Electrical stimulation: Helps patient find muscle and contract if weak
Pessaries: Late stage, just as good as surgery
What is surgery used for in POP?
Maintains vaginal capacity for sexual function
Restore/maintains bladder and bowel function
Relieves symptoms
What preventative measures are used in POP?
Avoid constipation
Effective management chronic chest pathology
Smaller family size
Improvements in antenatal and intra-partum care
What is urgency?
The complaint of a sudden, compelling desire to pass urine that is difficult to defer
What is urge incontinence?
The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency
What is frequency?
Usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids too often by day
What is nocturia?
Usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void
What is stress incontinence?
Leakage accompanying physical activity such as coughing, sneezing, heavy lifting, running, laughing etc
Describe Oxford grade 0 of pelvic floor muscles
No muscle activity
Describe Oxford grade 1 of pelvic floor muscles
Minor muscle activity
Describe Oxford grade 2 of pelvic floor muscles
Weak muscle activity without circular contraction
Describe Oxford grade 3 of pelvic floor muscles
Moderate muscle contraction
Describe Oxford grade 4 of pelvic floor muscles
Good muscle contraction
Describe Oxford grade 5 of pelvic floor muscles
Strong muscle contraction
Give risk factors for incontinence
>Age: increasingly fibrotic bladder
>Parity
Menopause
Smoking
Medical problems
Obesity: Increased intraabdominal pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery
How does incontinence present?
Irritation syndrome
- Urgency
- Increased daytime frequency (>7)
- Nocturia (>1)
- Dysuria
- Haematuria
Incontinence
Voiding symptoms
- Straining to void
- Interrupted flow
Prolapse
Bowel
- Anal incontinence
- Constipation
- Faecal evacuation
- Dysfunction
- IBS
What investigations are used in incontinence diagnosis?
Urine dipsticka and culture, to rule out UTI and diabetes
3 day urinary diary
Post voiding residual volume assessment
- Usually by bladder scanning, only if voiding difficulty symptoms
Urodynamics, only indicated if surgical treatment is contemplated
What is noted in the 3 day urinary diary?
Fluid intake
Urine out put excluding nocturnal polyuria
Daytime frequency
Nocturia
Average voided volume
What lifestyle changes are used in incontinence management?
Stop smoking
Lose weight
Eat healthy to avoid constipation
Stop drinking alcohol, caffeine, chocolate
What non surgical methods are used in incontinence management?
Pelvic Floor Muscle Training: Reinforcement of cortical awareness of muscle groups
Yentreve (Duloxetine): Should be part of an overall management strategy that should include pelvic floor muscle training
How often are pelvic floor muscle exercises done?
3 sets 5 x a day
When is duloxetine used?
Use if pelvic floor muscle training has failed or would be enhanced in primary care
Use if not fit for surgery, failed surgery in secondary care
Give adverse effects of duloxetine
Nausea
Mood change
Give the procedural/surgical methods used in incontinence management
Colposuspension/Surgery
Tension-free Vaginal Tape (TVT): Reinforces structures supporting the urethra
What is overactive bladder syndrome?
Symptom complex usually related to urodynamically demonstrable detrusor overactivity
Give risk factors for overactive bladder syndrome
Advanced age
Diabetes
Urinary tract infections
Smoking
What lifetsyle interventions are used in overactive bladder syndrome?
Normalise fluid intake,
Reduce caffeine/fizzy drinks/chocolate
Stop smoking
Weight los
What non pharmacological method is used in overactive bladder syndrome management?
Bladder training programme: Timed voiding with gradually increasing intervals
Give the pharmacological methods of overactive bladder syndrome management
Antimuscarinic/anticholinergic
Betmiga/Muscle relaxant
Tri-cyclic antidepressants used for nocturia
Botox: Injected into bladder to relax bladder/reduce contractions and reduce sensory pathway
Neuromodulation
What is first line medical management for stress incontinence?
Duloxetine, after adequate trial of pelvic floor training
What is first line medical management of urge incontinence?
Mucurinic antagonist, after trial of bladder retraining
