Urogynaecology AI generated Flashcards
1
Q
What is this?
A
A urethral caruncle - a benign tumour of the female urethra
Accounts for 90% of urethral masses in post-menopausal women
2
Q
What is the average age of presentation for a urethral caruncle?
A
68
3
Q
What are the histological features of a urethral caruncle?
A
Vascular connective tissue surrounded by transitional and squamous epithelial cells
Generally highly vascular and prone to thrombosis
4
Q
What are contributing factors to the development of a urethral caruncle?
A
- Age and post-menopause - decreased oestrogen levels
- Chronic irritation or inflammation
- Trauma
5
Q
What does a urethral caruncle typically look like and where do they typically arise from?
A
Soft, pink or red fleshy, exophylic lesion
<1cm in diameter
Typically arises from the posterior margin of external urethral meatus
- Can be pedunculated or sessile
- Generally highly vascular and are disposed to thrombosis, so on rare occasions they may look purple or black
6
Q
Do urethral caruncles typically obstruct the urethral orifice?
A
No
7
Q
What is the reported rate of carcinoma following excision of a urethral caruncle?
A
1.6 – 12%
8
Q
What proportion of women are asymptomatic with a urethral caruncle?
A
1/3
9
Q
What symptoms may women present with?
A
2/3s of women will be symptomatic
Symptoms include: dysuria, dyspareunia, bleeding (PV or haematuria), pain, UTI and rarely urine retention
10
Q
What features should raise suspicion for malignancy in a urethral caruncle?
A
- Bleeding to touch
- Irregular hard appearance
- Palpable pelvic lymphadenopathy
11
Q
What work-up may be performed when investigating a urethral mass?
A
Clinical diagnosis based on physical examination, and further investigation is unnecessary in the vast majority.
Physical examination involves speculum, bimanual and assessment of lymph nodes.
Further Ix depends on presenting symptom and may include:
* Urine microscopy and culture to exclude an infectious element
* Flexible or rigid cystocopy if the source of haematuria is unclear, or malignant pathologies need to be excluded
* USS or CT or MRI
* Hysteroscopy if suspected PMB or thickened ET on TVUSS
* Tissue biospy if there is suspiscion of malignancy
12
Q
What are the differential diagnoses for a urethral caruncle?
A
- Urethral prolapse
- Urethral polyp
- Para-urethral cyst
- Urethral diverticulum
- Condyloma
- Urethral carcinoma
- Bladder cancer
- Urethral leiomyoma
- Vulval cancer
13
Q
When should a patient be referred to secondary services for a urethral caruncle?
A
- Symptomatic or concerning features present, then red flag urology
- Any uncertainty but absence of concerning features, then consider red flag gynae or gynae guidance and advice services
- No clinical change despite trial of oestrogen, consider routine gynae review
14
Q
What is the management for an asymptomatic urethral caruncle?
A
No intervention required
15
Q
What medical treatment/s may be used for symptomatic urethral caruncles?
A
Trial of 6-week topical oestrogen
Improvement often noted within 6 weeks
Maximum benifit within 3-6 months
Sitz baths and topical NSADS or steroids may also be used although limited evidence for their effectiveness
Patients should continue to self-monitor for concerning features and be advised how/ when to seek help
16
Q
What are the indications for surgical management of a urethral caruncle?
A
- Failed medical management
- Uncertain diagnosis
- Thrombosis, significant or recurrent bleeding, or acute urinary retention
17
Q
What is the most common method of surgical removal?
A
Simple excision is often performed, but other methods include ligation, cauterization and laser vaporization.
Long-term low-dose topical vaginal oestrogens may be advised post-surgery to prevent recurrence
18
Q
What are potential risks associated with the surgical management of a urethral caruncle?
A
- Clot retention
- Meatal retraction
- Stenosis
- Infection
- Wound breakdown
- Recurrence
19
Q
What is Fowler’s Syndrome (FS)?
A
A rare disorder in which the urethral sphincter fails to relax leading to urinary retention in young women.
Characterized by an abnormally elevated urethral pressure profile, increased urethral sphincter volume, and abnormal electromyography (EMG) of the urethral sphincter.
20
Q
What are the clinical features of Fowler’s Syndrome?
A
Young women (usually in their 30s) typically present with painless urinary retention, large post-void residual volumes (>1000mls), and no urgency.
- Abdominal straining does not help empty the bladder
- Catheter insertion can be painful
- No evidence of urological, gynecological, or neurological disease
21
Q
What associations are commonly reported with Fowler’s Syndrome?
A
- Polycystic Ovary Syndrome (PCOS)
- Endometriosis
- Antecedent obstetric or surgical events
22
Q
What specialist tests may be used for diagnosing Fowler’s Syndrome?
A
- Concentric needle EMG of the urethral sphincter is diagnostic
- Urodynamics including cystometry and urethral pressure prolifometry
- Urethral ultrasound
- Concentric needle EMG of the urethral sphincter - specific type of abnormal activity, described as decelerating bursts, which sound like whale songs, and complex repetitive discharges, which sound like helicopters
- Cystometry - large bladder capacity without the usual sensations during the filling phase.
- Urethral pressure profilometry - elevated resting urethral closure pressure > 100cm H20
- USS +- MRI assessment of urethral sphincter - increased urethral sphincter volume
23
Q
What is the main treatment for Fowler’s Syndrome?
What is it’s success rate?
A
Sacral Neuromodulation (SNM) is the only treatment that has been found to restore voiding in women with FS.
Success rate is 72-78%
Although highly effective, it is expensive, resource-intense and associated with a high rate of complications with need for surgical intervention.
It works by overcoming sphincter afferent-mediated inhibition.
24
Q
What is Bladder Pain Syndrome (BPS) also known as?
A
Interstitial Cystitis (IC)
25
What are the characteristics of Bladder Pain Syndrome?
BPS is characterized by persistent or recurrent pelvic pain, pressure, or discomfort related to the bladder, along with at least one other urinary symptom.
## Footnote
* Symptoms may include urgency, frequency, or nocturia.
* Severity of BPS varies greatly from mild – debilitating
* May have “flares” e.g., menses, or “triggers” e.g., alcohol, citrus fruits, coffee, carbonated drinks
26
What is the prevalence of Bladder Pain Syndrome?
2-6%
F>M
90% of affected individuals are female
27
What are common conditions associated with Bladder Pain Syndrome?
* Irritable Bowel Syndrome (IBS)
* Vulvodynia
* Endometriosis
* Fibromyalgia
* Chronic fatigue syndrome
28
What factors are involved in the aetiology of Bladder Pain Syndrome?
BPS involves a complex interaction of bladder mucosal barrier dysfunction, activation of pain-signalling pathways, central sensitization, and urinary microbiome alterations.
29
What are some differential diagnoses for Bladder Pain Syndrome?
* Malignancy
* UTI
* STI
* Radiation or drug-mediated cystitis
* Bladder outlet obstruction
* Renal calculi
* Endometriosis
* IBS
30
What initial assessments are part of evaluating Bladder Pain Syndrome?
* Clinical assessment
* Medical history
* Physical examination
* Urine testing
* Bladder diary
* Food diary
## Footnote
Other Ix are guided by clinical picture and need to exclude DD
E.g., STI screening if pyuria and MSSU negative, or cystoscopy and biopsy if malignancy suspected
31
What conservative management strategies are recommended for Bladder Pain Syndrome?
* Dietary modification: Avoid caffeine, alcohol, acidic or spicy foods and drinks
* Stress management
* Regular exercise
* Simple analgesia
## Footnote
TOG 22 also suggests:
* Bladder training
* Avoid constipation
* Avoid UTIs
32
What oral pharmacological treatments are available for Bladder Pain Syndrome?
* Oral amitriptyline
* Oral cimetidine
* Pentosan polysulfate sodium * TOG 22
33
What is the role of neuromodulation in treating Bladder Pain Syndrome?
Neuromodulation includes:
* Posterior tibial nerve stimulation (PTNS )
* Sacral nerve stimulation (SNN).
Can be considered provided:
* And the above therapies have failed , it is refractory BPS
* MDT has reviewed
* Patient has been referred to pain clinic
## Footnote
* Greentop 2016 and TOG 22 both sources acknowledge neuromodulation as a treatment option for refractory BPS, with PTNS and SNS being the main forms mentioned.
* TOG also discusses central neuromodulation techniques, such as deep brain stimulation (DBS) and repetitive transcranial magnetic stimulation (r-TMS)
34
What considerations are there for BPS treatment during pregnancy?
Pregnancy has variable effects on BPS symptoms, with safe treatment options including oral amitriptyline and intravesical heparin.
## Footnote
DMSO should be avoided due to its teratogenic effects in animal studies
35
When should you a GP refer a patient with Bladder Pain Syndrome to secondary care?
Refer to secondary care should be done if conservative treatments have failed.
36
What could represent a possible outpatient-based alternative therapy for women with Fowler's Syndrome?
**Botulinum toxin**
Botox injections to the urethral sphincter *may* be considered for patients who are unable to perform intermittent self-catheterization (ISC) or unsuitable for SNM.
## Footnote
It is believed to work by blocking efferent signals from the sphincter by onabotulinum toxin A may reverse the inhibitory effects.
37
What is refractory BPS and how should it be managed?
BPS is refractory when it has failed to respond to conservative, oral and intravesical therapy.
They should be referred to an MDT and neuromodulation considered.
38
For Bladder Pain Syndrome (BPS), if oral pharmcological treatments have not worked, then what should be considered next?
Intravesical Treatments
Greentop states oral cyclosporin A may be considered after conservative, oral pharmacological, intravesical, and neuromodulation treatments have failed.
## Footnote
Includes lidocaine, hyaluronic acid, botulinum toxin A, dimethyl sulfoxide (DMSO), heparin or chondroitin sulfate
39
What role do long-term antibiotics have in the treatment of Bladder Pain Syndrome?
* Greentop states they are not recommended based on a lack of evidence for effectiveness and a high rate of adverse effects in clinical trials
* Following evidence published since 16 which have shown symptom improvement and reduction in bacterial levels, TOG 22 suggests that long-term, **low-dose antibiotics may have a role in managing BPS**
40
What are Hunner Lesions?
Rreddish mucosal lesions that lack normal capillary structure and bleed easily
They typically do not respond to oral treatments and therefore require cystoscopic fulguration and Nd:YAG laser treatment.
## Footnote
If they are indenifitied, consider Cystoscopic fulguration and Nd:YAG laser treatment as these lesions do not typically respond to oral treatments
41
What is the most common infection in women worldwide?
Urinary Tract Infections (UTIs)
## Footnote
UTIs are prevalent and particularly common among women.
42
Define recurrent UTI (rUTI).
At least three UTIs in a year, or two UTIs in six months.
43
What threshold level of bacteriuria indicates infection of the urothelium?
Greater than 10 (5) cfu/ml
## Footnote
However, levels below this can still cause chronic damage to the urothelium suggesting that ignoring ASB may not always be the best approach.
44
What is asymptomatic bacteriuria (ASB)?
Presence of bacteria in urine without symptoms.
## Footnote
* Common
* Prevalence increases with age and affects 20% in >60-year-olds
45
In which groups is ASB more common?
* Elderly
* Catheterised
* Nursing home residents
* Pregnancy
46
What percentage of pregnancies experience ASB?
2-10%.
47
What are some risks associated with ASB in pregnancy?
* Maternal and fetal complications
* Pyelonephritis
* Preterm birth
* Stillbirth
## Footnote
However evidence is conflicting or lacking.
48
What was the NICE recommendation for routine screening for ASB in pregnancy in 2008?
Routine screening was recommended.
49
What is the current NICE recommendation regarding ASB in pregnancy as of 2021?
## Footnote
o NICE Antenatal Care 2008 previously recommended routine screening for ASB in pregnancy, however as of 2021, this recommendation was removed
o NICE UTI (lower) – women 2024 recommends only women who are intermediate or high-risk of pre-term birth (SBL V3) should have an MSSU at booking and ASB treated with antibiotics
The recommendation for routine screening was removed.
50
What are the main risk factor for UTIs and rUTIs?
* Female
* Age (being post-menopausal)
* Use of spermicides
* Sexual intercourse
* Renal tract anomalies
* Pregnancy – this is due to the dilatation of the renal pelvis and ureters which can cause urinary stasis and bacterial colonization
* Young age at first UTI
* Family history
* High parity
* Lower socioeconomic status
51
What impact does hypoestrogenism have on UTI risk?
Increases vaginal pH, detrimental to normal vaginal flora.
52
List some complications of UTIs.
* Pyelonephritis
* Abscess formation
* Preterm birth
* Renal scarring
* Hypertension
* Chronic renal failure
* Psychological distress, anxiety and depression
53
What are common side effects of UTI treatments?
* GI symptoms
* Disturbance of microbiome leading to increased risk of bacterial vaginosis and candidiasis
* Pulmonary and liver toxicity from nitrofurantoin
54
What percentage of antibiotic prescriptions for UTIs are noted to be unnecessary or inappropriate?
50%
55
What should be done before beginning antibiotic treatment for a UTI?
* Full clinical assessment assessing for clinical symptoms and complications
* Urinalysis and MSU for culture and sensitivities
56
What investigations might be done if rUTI is suspected?
* Renal ultrasound
* Cystoscopy
* Urodynamic testing
## Footnote
Must refer to secondary care to allow for further investigation and management
57
What management options are considered for recurrent UTIs?
* Identify and treat the cause
* Low-Dose Antibiotic Prophylaxis
* Non-antimicrobial preventive treatments
58
What is a non-antimicrobial preventive treatment for postmenopausal women?
Vaginal oestrogen.
59
What alternative treatment may be offered to premenopausal women with normal investigations?
GAG replacement therapy with synthetic hyaluronic acid.
## Footnote
* GAG layer of the urothelium is a protective antibacterial coating of the bladder
* Chronic infection can result in disruption or depletion of this layer, increasing the risk of bacterial adherence and the rate of UTI which results to further chronic urothelial damage and neurogenic inflammation
* Damage to the urothelial cells beneath the GAG layer is thought to be critical to most chronic bladder pathologies.
60
Is cranberry juice recommended by NICE for recurrent UTIs?
No.
61
What is D-mannose?
A sugar from cranberry juice that may help with UTI recurrence.
## Footnote
Prevents bacterial adherence to uroepithelial cells, causing bacteria to be simply excreted in urine when voiding.
Safe in pregnancy.
NICE recommends nonpregnant women may wish to try D-mannose as a self-care treatment
62
What is the prevalence of Stress Urinary Incontinence (SUI) during pregnancy?
How does prevalence change over pregnancy and the postnatal period?
* SUI is the most common type of UI in pregnancy
* Prevalence **19% - 75%**
* Becomes more prevalent as the pregnancy progresses
* More prevalent at 6 weeks postpartum in those that had a vaginal delivery compared to a C-Section
63
Does mode of delivery affect SUI recurrence following surgery?
No
## Footnote
Mode of delivery does not significantly alter the likelihood of SUI recurring after a woman has undergone surgery to correct it
64
What is the first-line management for SUI during pregnancy?
Lifestyle modifications and pelvic floor muscle training (PFMT)
## Footnote
* Surgery typically postponed until after the woman has completed her family.
65
How does PFMT impact SUI in pregnancy?
There is no evidence that FMT improves urinary leakage in women who are already suffering with this.
However, if performed in **early pregnancy**, it **may prevent the onset of urinary incontinence in late pregnancy and postpartum**
66
What is the prevalence of urinary urgency during pregnancy?
How does prevalence change during pregnancy and the postnatal period?
* Urinary urgency affects **16% - 31% ** of women during pregnancy.
* Prevalence increases with increasing gestation.
* All LUTS tend to improve by 6 weeks postnatal, however long-term OAB is higher in those who had a vaginal delivery in comparison to a C-Section.
## Footnote
Up to 41% of pregnant women may experience micturition frequency, especially in the first trimester.
67
Can antimuscarinics be used to treat OAB in pregnancy?
Oxybutynin immediate release (IR) can be used in pregnancy and breastfeeding, but its safety has not been fully established
68
What can be used to treat OAB in breastfeeding individuals until BF is complete or periods return?
Low dose vaginal oestrogen
## Footnote
In the postpartum, especially during breastfeeding, hypoestrogenism can lead to a reduction in lactobacillus. As lactobacillus contributes to maintaining a low pH which helps prevent infection, reduced levels contribute to an increased susceptibility to rUTI.
69
Can Botox be used in pregnancy to treat OAB?
Botox may be considered, but it is not commonly offered.
There is no evidence to suggest it increases risk of adverse pregnancy outcomes or congenital abnormalities.
70
Can neuromodulation be used to treat OAB in pregnancy?
P-SNM is NOT offered during pregnancy.
If already in place, it should be turned off in pregnancy.
71
What is the incidence of UTIs during pregnancy?
Prevalence of acute UTI during pregnancy is 8%, with pyelonephritis occurring in 2%
## Footnote
Pregnancy-related changes increase the risk of UTIs due to urinary stasis.
72
What treatment options can be considered in rUTI in pregnancy?
* Long term antibiotic prophylaxis
* Methanamine Hippurate (Hiprex)
* D-Mannose
73
What are 2 causes of urinary retention during pregnancy?
* Fixed retroverted uterus
* Inefficient bladder emptying during labour, and other complications
## Footnote
Up to 20% of women may have a retroverted uterus.
74
When does urinary retention caused by a fixed retroverted uterus tend to present?
Typically presenting between 14 and 18 weeks.
## Footnote
Retroverted uteruses usually corrects itself as the uterus enlarges. Rarely (1 in 3000–10,000 pregnancies) the retroverted uterus may become fixed as a resulting of getting trapped under the sacral promontory, resulting in urinary retention.
In most cases, urinary retention resolves as the uterus grows and exist the pelvis.
Treatment: catheterisation or clean ISC. Rarely, if the retroversion does not resolve, the fundus of the uterus may need to be freed from the sacral hollow vaginally under GA
75
What is the prevalence of postpartum urinary retention (PUR)?
A common condition after childbirth, with prevalence ranging from **14% to 24%**
## Footnote
It can be classified as overt or covert based on the ability to void spontaneously.
76
What is overt PUR?
The inability to void spontaneously within 6 hours of a vaginal delivery or after TROC post CS
77
What is covert PUR?
A PVR ≥150 mL after spontaneous micturition, confirmed via bladder ultrasound or catheterization
78
What are the risk factors for PUR?
* Vaginal delivery (over CS)
* Epidural analgesia
* Prolonged labor
* Instrumental delivery
* Episiotomy
* Primiparous
79
What are the VESSI Questions and what are they used to assess?
King’s College Hospital TWoC Protocol guides management of postnatal bladder care. It uses the VESSI Questions which aims to identify women at risk of urinary retention.
1. Did you pass a good Volume of urine?
2. Did your bladder feel Empty at the end?
3. Do you have a Sensation that you want to pass urine?
4. Was your Stream normal?
5. Was there any Incontinence?
80
What is prevalence of POP postpartum?
* Prevalence of POP is** 5% to 10%**
* POP prevalence and surgical repair is more prevalent in women who had VD in comparison to C-Section
81
Damage to which leaf of the levator ani muscle during childbirth increases risk of POP?
Puborectalis muscle of the levator ani
82
What are pregnancy-related risk factors for POP?
* Vaginal delivery
* Forceps
* Prolonged 2nd stage of labour
* LGA
* OASIS
83
How are POPs managed in pregnancy?
* Conservative measures: Lifestyle adjustments (manage constipation and quit smoking), diet and exercise for weight management, PFMT, and vaginal pessaries
* Surgery is not recommended until after the woman has completed her family
84
What proportion of people with urethral caruncles are symptomatic versus asymptomatc?
What symptoms may they present with?
* 2/3 symptomatic - dysuria, pain, haematuria, dyspareunia, vaginal bleeding, vaginal discharge, UTI and rarely urine retention
* 1/3 asymptomatic
| pain, dysuria,
85
Does the use of ultrasound imaging in urogynaecology involve methods that have been standardised by international societies?
Yes, scanning methods have been standardised in a collaboration between six international societies.
86
What is the best position for patients to adopt during transperineal ultrasound (TPUS)?
Dorsal lithotomy position, with the hips abducted and flexed
87
Should the bladder be full or empty during TPUS?
Empty
88
What is the prevalence of levator ani muscle avulsion in women who have a vaginal delivery?
10-36%
89
What is the significance of levator ani muscle avulsion?
Regarded as the major causative factor explaining the association between vaginal childbirth and the development of POP
90
What is the gold-standard tool for diagnosing levator ani muscle avulsions?
Transperineal ultrasound (TPUS) using multi-slice or tomographic imaging (TUI)
## Footnote
Multi-slice or tomographic imaging (TUI) enables simultaneous observation of the effect of contraction and Valsalva at different levels. This allows for assessment of the levator ani muscle and allows for diagnosis of avulsion.
91
What observation made during TPUS using tomographic imaging diagnoses a levator ani muscle avulsions?
Observation of a defect in the insertion of the LAM in the 3 central slices of tomographic set of axial plane images.
92
What does a 2D sagittal view show?
* Bladder neck
* Urethra
* Pelvic floor
* Puborectalis muscle
## Footnote
Allows for identification of PVR and detrusor wall thickness.
93
How are 2D coronal views obtained following sagittal assessment?
By rotating the probe through 90 degrees in a clockwise direction.
94
What does a 2D coronal view show?
Anal canal and sphincter complex
## Footnote
IAS and EAS are seen as a bull’s eye pattern
95
What sort of pressure should be applied when assessing IAS and EAS using TPUS?
Minimal pressure
## Footnote
Minimal pressure should be applied, as compression of the anal sphincter can be seen to flatten the sphincter.
96
Is detrusor wall thickness (DWT) a reliable marker for detrusor overactivity?
No
97
How is urethral mobility measured?
By measuring the bladder neck displacement (BND) and urethral rotation during Valsalva.
98
Where there is a cystocoele with an intact RVA, what symptoms do patients typically present with?
Prolapse and voiding dysfunction rather than SUI
99
What is the role of ultrasound in clinical urogynaecology practice?
Ultrasound is a cost-effective, accessible, and reproducible assessment tool for various pelvic floor conditions.
100
What types of assessments can ultrasound provide in urogynaecology?
* Diagnosis and treatment choice in lower urinary tract disorders
* POP assessments
* Evaluation of defecatory disorders
* Assessment of birth traumas
* Assessment of presence- and type- of midurethral sling, and presence of
complications
101
What views are used in transperineal ultrasound imaging?
* 2D sagittal views
* 2D coronal views
* 3D or 4D views
102
What is required in its most basic form for TPUS?
* A B-mode 2D USS machine
* A cine-loop function
* A 3.5 to 6-MHz curved array transducer
103
What is the significance of measuring post-void residual (PVR) volumes?
Large PVR measurements are indicative of poor voiding function.
## Footnote
PVR of >100 would caution against use of Botox for Tx of OAB
While preoperative PVR is not predictive of urinary retention after midurethral sling (MUS) placement, it should prompt further investigation before sling placement.
104
What is the formula for measuring PVR using TPUS on a 2D sagittal view?
PVR = X * Y * 5.6
## Footnote
Where X and Y are the two maximal perpendicular measurements in cm of bladder size.
105
Is detrusor wall thickness (DWT) measured transperineally or transvaginally on 2D scan?
Either
106
What does an increase in detrusor wall thickness (DWT) indicate?
It may be associated with several bladder pathologies including bladder outlet obstruction.
107
Is DWT a good predictor of OAB?
No, DWT may support the diagnosis of OAB; however it is not a good predictor of OAB
## Footnote
* Poor interobserver reproducibility
* Poor correlation between bladder wall thickness and urodynamic detrusor overactivity.
108
How is urethral mobility quantified?
By measuring the bladder neck displacement (BND) and urethral rotation during Valsalva.
109
What findings support the diagnosis of intrinsic sphincter deficiency (ISD)?
* Decreased urethral volume
* Marked funnelling on Valsalva
* Lack of urethral mobility in the presence of SUI
110
What is the POP-Q clinical staging system used for?
It is used for staging prolapse but does not yield information on anything but vaginal and perineal surface anatomy.
111
During 4D imaging assessment, downwards descent of the prolapsed organ is visualised and quantified against a horizontal reference line.
What margin is this reference line placed through?
The inferoposterior symphyseal margin
112
What is the RVA and how does it distinguish a cystococoele from a cystourethrocoele?
* RVA = retrovesical angle at Valsalva
* RVA <140 degrees = a cystocoele
* RVA >140 degrees = cystourethrocoele
## Footnote
4D imaging assessment of POP allows for differentiation between a cystocoele and cystourethrocoele, as well as rectocoele from enterocoele and rectal intussusception.
113
What is the significance of a hiatal area over 25 cm²?
It is referred to as ‘ballooning’.
## Footnote
* Overstretching of the LAM fibres during crowning of the fetal head at the first delivery results in considerable microtrauma, altering the distensibility and thus levator hiatal dimensions.
* An enlarged hiatus is likely to increase forces acting on the support structures of pelvic organs and has been shown to be strongly associated with POP symptoms and prolapse recurrence.
114
What is the major risk factor for levator ani muscle avulsion during vaginal delivery?
Forceps
115
What is an anal residual sphincter defect?
A defect in the circumference of the EAS of ≥30 degrees in at least two out of three slices on endoanal sonography.
116
What percentage of patients with previous OASI are found to have residual sphincter tears detected in follow-up TPUS?
Up to 40% of patients
117
What does the RCOG recommend for patients with previous severe OASI?
A C-Section should be offered.
## Footnote
However, there is evidence that those with previous OASI who are asymptomatic and without residual EAS defect may deliver vaginally with comparable outcomes to patients without previous OASI.
118
What are the 2 types of prosthetic materials used in reconstructive pelvic floor surgeries?
1. Biological - grafts
2. Synthetic - meshes
119
Name the 3 types of biological grafts
1. Autologous - patients own tissues, typically the rectus sheath and fascia lata
2. Allograft - donor human tissue, typically cadaveric tissue that has been sterilised
3. Xeonografts - donor non-human tissue, typically porcine or bovine
120
What risk does autologous grafts carry that the other types don't?
Risk of site morbidity e.g., wound infection, scar, nerve damage and hernia
121
What are the benefits of allografts?
Allografts use human donor tissue, typically cadaveric tissue. This avoids site morbidity and saves time during the operation
122
What are the risks of xenografts?
Risk of disease transmission and inconsistency of tissue strength
## Footnote
Xenografts use acellular extracts of collagen from nonhuman tissue, typically porcine or bovine
123
What did the 2017 PROSPECT study conclude about biological grafts?
At 2 years, women in the graft group were more likely to report a feeling of "something coming down" than those who had standard native tissue repair, even though no objective increased failure rate was identified
## Footnote
Other sources suggest, biological grafts are associated a higher failure rate and need for repeat surgery
124
What are the two types of synthetic meshes?
Absorbable and non-absorbable
125
Give an example of a synthetic **absorbable** mesh.
* Polyglactin
* Polyglycolic acid
## Footnote
Undergo replacement by collagen-rich connective tissues
Animal studies demonstrate poor long-term tensile strength and early recurrence of hernia
126
Give an example of a synthetic **non-absorbable** mesh.
* Polypropylene
* Polytetrafluoroethylene
127
What are the risks of synthetic non-absorbable synthetic meshes?
* Host reaction
* Mesh contracture and/or exposure
128
What classification system is used for synthetic non-absorbable mesh?
* Amid classification 1997
* It uses pore size
* 4 Types
129
According to the Amid classification, what is the type of non-resorbable mesh used in vaginal surgery?
Type 1 is the only class used in both vaginal and abdominal mesh surgery
**Polypropylene monofilament** (Prolene) is the only mesh that should be used in vaginal surgery, and this is a type 1 mesh
130
What is the pore size of type 1 mesh?
Greater than 75 um
## Footnote
This pore size permits infiltration by fibroblasts, blood vessels, collagen fibres and macrophages, which promotes tissue incorporation and reduces the risk of infection.
131
Describe the qualities of Type 1 meshes?
* Macroporous
* Monofilamentous
* All pore sizes >75um
132
Describe the qualities of Type 1 meshes?
Macroporous and microporous
133
What was the FDA 510(k) pre-market notification process?
Allows manufacturers to bring a new product to market without rigorous testing if deemed 'substantially equivalent' to a legally marketed device.
134
What was the first vaginal mesh approved for surgical management of SUI?
In **1996**, **ProteGen®** was approved under the FDA 510(k) pre-market notification process.
It was predicated on mesh devices previously approved for hernia repair and no further testing was deemed necessary, despite a lack of clinical safety trials for transvaginal placement.
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When was the first tension-free-vaginal-tape (TVT) cleared and how was this done?
In 1998, J&J TVT was approved under the FDA 510(k) pre-market notification process, based on its similarity to ProteGen®
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What happened to ProteGen® in 1999?
It was recalled by Boston Scientific due to safety concerns.
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After ProteGene® was recalled, what happened J&J TVT?
Nothing - J&J TVT was not recalled
Between 2001 and 2008, further TVT's were cleared, and all of these can all be traced back to ProteGene®
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When was the first mesh cleared for the surgical treatment of POP?
2002
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What was the trend in the use of transvaginal mesh in the late 1990s?
Adopted rapidly due to perceived lower invasiveness and morbidity, and theorized lower risk of recurrence.
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In 2010, what porportion of surgical POP repairs in USA used mesh?
1/3rd
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What significant safety announcement did the FDA make in 2008?
Issued a Public Health Notification alerting clinicians to adverse events associated with transvaginal mesh.
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When was a further safety communication issued by the FDA?
In 2011, the FDA systematic review found that transvaginal POP repair with mesh did not improve symptomatic results or QOL over traditional non-mesh repair and introduced additional risks
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What did the FDA do which led to manifacturers stopping production?
In 2016, the FDA reclassifed mesh
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What was the conclusion of the 2016 Scottish population-based cohort study?
* Mesh procedures for anterior and posterior compartment prolapse, in comparison to native tissue repaire, were less effective and associated with a higher complication rate.
* Mesh cannot be recommended for primary prolapse repair.
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What did the 2017 PROSPECT study look at?
Compared women undergoing primary anterior or posterior repair to standard native tissue repair or repair augmented with synthetic mesh or biological graft.
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What were the key findings?
* Prolapse symptoms, QOL, dyspareunia similar between the groups.
* Objective POP-Q assessment showed no difference in failure between the groups
* At 2 years, 6% of women had undergone further prolapse surgery, with no difference between groups
* Serious adverse events occurred with similar frequency in groups
* Synthetic mesh complication rate was 12%, with 9% requiring surgical removal
## Footnote
Conclusion: Women do not benefit from having their first prolapse repair reinforced with synthetic mesh or a biological graft in the first 2 years after surgery, either in terms of prolapse symptoms or anatomical cure
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What is the synthetic mesh-related complication rate?
12%
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How many needed surgical removal of mesh?
9%
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Whats is the biological graft-related complication rate?
<1%
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What urinary tract problems are more common in those who had synthetic mesh repair than in those who had a native tissue repair?
Bladder injury
Urinary retention
De novo SUI
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Are mesh repairs associated with reduced rates of recurrence of POP?
No difference in objective failure between the mesh- and non-mesh POP repair
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When does NICE recommend offering mesh surgical options for POP surgery?
* For women with a vault prolapse, offer a **sacrocolpopexy**
* For women with a uterine prolapse, offer a **sacrohysteropexy**
* These are done via abdominal or laparoscopic approach
* Transvaginal mesh repair is not recommended
## Footnote
Transvaginal mesh repair of anterior or posterior vaginal wall prolapse have serious well-recognised safety concerns, and therefore should only be used in the context of research as current evidence
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When does NICE recommend offering mesh surgical options for SUI surgery?
Women who have had failed non-surgical management and want surgery can be offered the choice of:
* Autologous rectus fascial sling
* Rectopubic mid-urethral sling
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What should patients be made aware of according to the Montgomery ruling and GMC guidance?
All treatment options, including expectant, conservative, and surgical options, including mesh- and non-mesh options
## Footnote
This emphasizes the importance of shared decision making in patient care.
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What type of mesh should be used if mesh is indicated?
Type 1 polypropylene mesh
## Footnote
This specification is crucial for minimizing complications.
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Local MDTs should review proposed treatment for women offered invasive procedures for....
* Primary SUI
* OAB
* Primary POP
## Footnote
They should work within a clinical network that has access to regional MDT
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Regional MDTs should deal with complex pelvic floor dysfunction and mesh related problems, and review proposed treatment in cases involving...
* Repeat continence surgery
* Repeat same-site prolapse surgery
* Preferred treatment option unavailable in referring hospital
* Coexisting bowel problems needing additional intervention
* Patient wishing vaginal mesh for prolapse as a treatment option
* Mesh complications or unexplained symptoms
* Considering surgery with future pregnancy in mind
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Women having surgery for SUI or POP, or have experienced complication relate dto these types of surgeries should have their data recorded in which National Database?
BSUG national database
## Footnote
Recommended by NICE, NHS England, and NHS Scotland.
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What is the purpose of the BSUG national database?
To report annually and be quality assured on surgeries for SUI or POP
## Footnote
It collects data on procedures and complications for better oversight.
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What information should be recorded for patients undergoing surgery?
* H&C number
* Consultant and hospital identifiers
* Date and details of the procedure
* Mesh procedures: mesh material, manufacturer, product unique identification code, and type of sutures used
* Colposuspension: type of sutures used
* Bulking agent: bulking material, manufacturer, product unique identification code
* Investigation details for complications
* Follow-up data on outcomes
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Whose responsibility is it to collect and record this data? What other considerations are there?
Responsbility of the surgeon
The patient should be consented for this, and they should recieve a copy of their data
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Where should all complications specifically related to the use of devices and mesh be reported to?
Medicines and Healthcare Products Regulatory Agency (MHRA)
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What terminology should be used when documenting mesh-related complications?
IUGA/ ICS terminology
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What symptoms might indicate a mesh-related complication after surgery?
* Pain or sensory change in back, abdomen, vagina, pelvis, leg, groin, or perineum
* Vaginal problems (discharge, bleeding, dyspareunia)
* Urinary problems (RUTI, incontinence, retention, dysuria)
* Bowel problems (difficulty or pain on defecation)
* Symptoms of infection
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What should be included in a specialist assessment for suspected mesh-related complications?
* Surgical history
* Validated pelvic floor symptom questionnaire and pain questionnaire
* VE to assess mesh palpability/exposure/extrusion
* Consider PR and neuro exam
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What investigations can be used for mesh-related complications?
* EUA
* Cystourethroscopy
* Sigmoidoscopy for suspected bowel perforation
* Laparoscopy
* USS (TPUS, TVUS, Translabial, or 3D), CT, or MRI
* Fluoroscopic studies (cystography or contrast enema)
* Urinary flow studies and PVR assessment or cystometry
* Nerve conduction studies if suspected nerve damage
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If mesh-related complication is confirmed or there are unexplained symptoms after a mesh procedure, what should be done?
Refer to a consultant at a regional centre specialising in the diagnosis and management of mesh-related complications
**or**
If there is vaginal exposure of mesh <1 cm2 and no other symptoms, discuss topical oestrogen and offer f/u appointment within 3 months
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What should be discussed if a woman is considering mesh removal?
* Limited evidence on the benefits of removal compared with no mesh removal, and so removing mesh might not relieve symptoms
* Complete removal may not be possible; however, partial removal may be just as effective at improving symptoms as complete removal
* Potential complications: organ injury, worsening pain, and urinary, bowel and sexual dysfunction, recurrence of previous symptoms e.g., SUI, prolapse, bowel problems
* Further surgery may be required
## Footnote
Complete removal may not be possible; partial removal might improve symptoms.
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Is the risk of recurrent SUI higher with complete or partial mesh removal?
Complete
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When can topical oestrogen be offered?
Single area of vaginal mesh exposure < 1 cm2
## Footnote
Surgical removal should be considered if:
There's no response to treatment
If the patient does not want to try oestrogen
Area of mesh exposure is >1cm
There is vaginal mesh extrusion
