Urogynaecology and pelvic floor Flashcards
Causes of a vesicovaginal fistula
Obstructed labour
Following benign gynaecology surgery - e.g TAH
Following surgery for gynaecological malignancy
Pelvic radiotherapy
Pelvic TB
Vaginal erosion of a neglected foreign body e.g. Pessary
First management of genuine stress incontinence
Lifestyle measures
and
Pelvic floor physiotherapy
Management of genuine stress incontinence
Lifestyle measures + Weight loss
Pelvic floor physio
Surgical options - Midurethral sling / Pubovaginal sling/ Colposuspension (bladder neck suspension)
If wants to avoid surgery consider
Duloxetine (SNRI)
Oxybutynin or tolterodine (anticholinergic)
Vaginal estrogen if atrophic
Dietary modification suggestions for urge incontinence
Citrus fruits and flavourings Acidic PH Caffeine Spicy foods and chillis Chocolate Fizzy drinks Artificial sweeteners
1st line treatment for overactive bladder
Oxybutynin
What patient group should oxybutynin be avoided
Oxybutynin shouldn’t be given to frail elderly patients
Management of OAB prior to initiating anticholinergics
Prior to initiating anticholinergics
- Bladder training
- Consider treating vaginal atrophy and nocturia with topical oestrogen
- desmopressin
First line OAB anticholinergics
1st line treatments:
- Oxybutynin (immediate release)
- Tolterodine (immediate release)
- Darifenacin (once daily preparation)
Mirabegron, if an antimuscarinic is contraindicated
What is the stepwise approach to managing stress incontinence
stress incontinence treatment should follow a stepwise approach:
Lifestyle measures
Pelvic floor training
Consider invasive procedures
When should women be referred to the urogynaecology MDT
women with primary stress urinary incontinence, overactive bladder or primary prolapse should be referred for MDT review if
- offered invasive procedures for primary stress urinary incontinence, overactive bladder or primary prolapse
- Regional MDTs deal with complex pelvic floor dysfunction and mesh-related problems
Categories of urinary incontinence
stress urinary incontinence,
mixed urinary incontinence
urgency urinary incontinence/overactive bladder.
In mixed urinary incontinence what should treatment be directed at first?
direct treatment towards the predominant symptom
Lifestyle interventions for urinary incontinence
Lifestyle interventions for urinary incontinence
A trial of caffeine reduction to women with overactive bladder
Advise women with a high or low fluid intake to modify their fluid intake
Advise women who have a BMI greater than 30 to lose weight
Non-surgical management of urinary incontinence
Lifestyle interventions
- reduce caffeine
- reduce fluid intake if high
- reduce BMI if >30
Pelvic floor training
Bladder trainingWhat should Pelvic floor muscle exercises comprise of?
at least 8 contractions performed 3 times per day
When should electrical stimulation and/or biofeedback for pelvic floor exercises be considered
for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy
When should bladder catheterisation be considered for management of urinary incontinence
If persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction
and cannot otherwise be corrected.
intermittent catheterisation to women with urinary retention who can be taught or have a carer who can
long-term indwelling urethral catheters for women
- unable to self catheterise
- skin wounds, pressure ulcers, irritations being contaminated by urine- distress / disruption caused by bed / clothing changes
- patient preference
- distress / disruption caused by bed / clothing changes
Indwelling suprapubic catheters considered as alternative to long-term urethral catheters
NICE guidance on complementary therapies for urinary incontinence
Do not recommend complementary therapies for the treatment of urinary incontinence or overactive bladder.
When should transdermal treatment be offered for overactive bladder?
Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines
When may desmopressin be considered for women with incontinence?
desmopressin may be considered specifically to reduce
nocturia
in women with urinary incontinence or overactive bladder who find it a troublesome symptom
When may duloxetine be offered as a treatment for women with stress urinary incontinence
Do not routinely offer duloxetine as a second-line treatment for stress urinary incontinence
may be offered second-line if women prefer pharmacological to surgical treatment
or are not suitable for surgery
What type and when are hormonal treatments advocated by NICE for women with incontinence
Offer intravaginal oestrogens postmenopausal women with vaginal atrophy
and
overactive bladder symptoms
When should Botox be offered for urinary incontinence
offer bladder wall injection
For overactive bladder caused by detrusor overactivity
that has not responded to non-surgical management, including pharmacological treatments
Consider for overactive bladder without detrusor overactivity if the woman does not wish to have other invasive treatments.
What type of Botox is used for urge incontinence with detrusor overactivity?
bladder wall injection
with botulinum toxin type A
= longer duration of effect than type B
when should Percutaneous sacral nerve stimulation be offered for urinary incontinence
offer percutaneous sacral nerve stimulation
if overactive bladder has not responded to non-surgical management including medicines
AND
have not responded to botulinum toxin type A
OR
they decline Botox
What types of surgery does NICE recommend for managing stress urinary incontinence?
NICE recommends 3 types of surgery for managing stress urinary incontinence if other treatments failed
- colposuspension
- autologous rectus fascial sling
- a retropubic mid-urethral mesh sling (tape)
Does colposuspension or a retropubic mid-urethral mesh sling carry a higher risk of subsequent pelvic organ prolapse?
Pelvic organ prolapse more likely after colposuspension than a retropubic mesh sling
What happens in colposuspension surgery?
It involves lifting up the tissue around the neck of the bladder, and suspending it in this lifted position using synthetic stitches
Permanent or dissolvable
What is done In a Rectal fascial sling operation?
A sling is made using the rectus fascia from the abdomen.
The sling is placed behind the urethra to support it.
And stitched to the inside of the abdomen
What is done in a recto-pubic mesh sling?
This involves placing a strip of synthetic mesh behind the urethra to support it in a sling
The strip of mesh sometimes called a tape.
mesh is permanent
lifestyle advice for women with pelvic organ prolapse
losing weight, if BMI > 30
minimising heavy lifting
preventing or treating constipation
What is mirabegron?
Mirabegron= selective beta 3 agonist
relaxes the bladder detrusor muscle and enhances urine storage
licensed for OAB if antimuscarinic CI
