Urogynaecology and pelvic floor problems

Question 1

What is prolapse?

Answer 1

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

Question 2

What is a urethrocoele?

Answer 2

Prolapse of the lower anterior vaginal wall, involving the urethra only

Question 3

What is a cystocoele?

Answer 3

Prolapse of the upper anterior vaginal wall, involving the bladder - this can cause urinary frequency and incomplete bladder emptying

Question 4

What is an apical prolapse?

Answer 4

Prolapse of the uterus, cervix and upper vagina

Question 5

What is an enterocoele?

Answer 5

Prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel.

Question 6

What is a rectocoele?

Answer 6

Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum

Question 7

What ligaments support the cervix and upper third of the vagina?

Answer 7

The cardinal and uterosacral ligaments

Question 8

What ligaments attach the mid portion of the vagina to the pelvic sidewalls laterally?

Answer 8

Endofascial condensation

Question 9

What supports the lower third of the vagina?

Answer 9

Levator anti muscles (pelvic floor) and perineal body

Question 10

What causes prolapse?

Answer 10

• Multiple vaginal deliveries and pregnancy
• Congenital factors
• Menopause (deterioration of connective tissue)
• Pelvic surgery

Question 11

What would a woman with a prolapse describe in a typical history?

Answer 11

A ‘dragging, lump’ sensation, which is usually worse at the end of the day
Ask about bladder and bowel changes, and bleeding or unusual discharge

Question 12

How should a suspected prolapse be investigated?

Answer 12

• Pelvic ultrasound

- Urodynamic testing

Question 13

How can a prolapse be treated conservatively?

Answer 13

Pessaries (act like an artificial pelvic floor, and changed every 6-9 months)

• Ring pessary
• Shelf pessary (more severe)

Question 14

What may be given alongside pessaries to prevent vaginal ulceration?

Answer 14

Topical oestrogen or standard HRT

Question 15

How can a uterine prolapse be treated surgically?

Answer 15

• Vaginal hysterectomy (doesn’t actually repair the damaged levator ani, can lead to vaginal vault prolapse)
• Hysteropexy (attach uterus and cervix to sacrum using a mesh)

Question 16

What is a vaginal vault prolapse?

Answer 16

When the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina

Question 17

How can a vaginal vault prolapse be treated surgically?

Answer 17

• Sacrocolpopexy (fixes the vault to the sacrum using a mesh)
• Sacrospinous fixation (performed vaginally, suspend the vault to the sacrospinous ligament)

Question 18

How are -pexys performed?

Answer 18

They can be open or laparoscopic

Question 19

How can a vaginal wall prolapse be treated surgically?

Answer 19

Repair the wall and use synthetic meshes for support

Question 20

What two things do the filling stage of the urinary cycle depend on?

Answer 20

1. Adequate bladder capacity

2. Competent urethral sphincter

Question 21

What two things do the voiding stage of the urinary cycle depend on?

Answer 21

1. Detrusor contractility

2. Coordinated urethral relaxation

Question 22

How much urine can our bladders store?

Answer 22

500mL - although the urge to void starts at around 200mL

Question 23

How does the micturition reflex work?

Answer 23

Distention of the bladder wall causes contraction of the detrusor muscle via parasympathetic nerve fibres, controlled by the pons.

Question 24

When does micturition occur, in terms of pressure?

Answer 24

Bladder pressure > urethral pressure

This occurs because:

1. Detrusor muscle causes increased bladder pressure
2. Pelvic floor relaxation causes decreased urethral pressure

Question 25

What are the two main mechanisms causing female urinary incontinence?

Answer 25

1. Uncontrolled increases in detrusor pressure (overactive bladder) (35%) (urine leaks as soon as you feel an urge)
2. Increased intra-abdominal pressure transmitted to the bladder but not the urethra (stress incontinence) (50%)- usually due to weakened pelvic floor muscles or urethral sphincter

NB - usually intra-abdo pressure should be equally distributed to the bladder and urethra, so coughing shouldn’t usually alter this.

Question 26

What are common urinary symptoms to ask about?

Answer 26

• Urinary incontinence
• Daytime frequency (should be 4-7)
• Incomplete emptying
• Urgency
• Bladder pain/dysuria
• Haematuria
• Nocturia
• Nocturnal enuresis (incontinent at night)

Question 27

How can the urinary tract be investigated?

Answer 27

URINARY DIARY
MICROBIOLOGY - urine dipstick for presence of UTI
URODYNAMICS - see other question
CYTOSCOPY - inspection of the bladder cavity
IMAGING:
USS - exclude incomplete bladder emptying
CT - look at ureter with contrast
Methylene dye test - look at leakage using a blue dye

Question 28

How does urodynamics (cystometry) work?

Answer 28

It uses catheters to look at:

• bladder pressure on coughing with a full bladder
• abdo pressure using a pressure transducer in the rectum

Question 29

How can the true detrusor pressure be worked out?

Answer 29

Bladder pressure - abdo pressure

(because bladder pressure = abdo pressure + detrusor pressure)

NB - detrusor pressure should not increase during filling or coughing

Question 30

How are urodynamic studies interpreted?

Answer 30

If there is an involuntary detrusor contraction during the test, the patient has an overactive bladder

If there is leakage during the test, the patient has urodynamic stress incontinence

Question 31

What are some common causes for USI?

Answer 31

• Pregnancy and vaginal delivery
• Obesity
• Age
• Prolapse (cystocoele, urethrocoele)
• Previous hysterectomy

Question 32

How can USI be managed conservatively?

Answer 32

• Pelvic floor muscle training (do 8 contractions 3x a day)

- Vaginal cones or sponges (held in position by voluntary muscle contraction)

Question 33

How can USI be managed medically?

Answer 33

Duloxetine (SNRI) - enhances urethral sphincter activity

Question 34

How can USI be managed surgically?

Answer 34

Transvaginal polypropylene tape:
- Tension free tape
- Transobturator 
Colposuspension (lifting up the neck of the bladder)
Sling procedures
Artificial sphincter

Question 35

How does tension free tape work?

Answer 35

It is placed in a U shape around the urethra (minimally invasive but small risk of bladder perforation)

Question 36

How does trans-obturator tape work?

Answer 36

It is passed via the transobturator foramen and through some muscles (even less invasive)

Question 37

How is overactive bladder defined?

Answer 37

Urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of proven infection

You may get frequent passing of small volumes of urine

Question 38

What causes overactive bladder?

Answer 38

IDIOPATHIC, underlying neuropathy (MS)

Question 39

How is overactive bladder managed conservatively ?

Answer 39

Reduce fluid intake, medication review, bladder training (resist sensation of urgency and void according to a timetable)

Question 40

How is overactive bladder managed medically?

Answer 40

• Anticholinergics
• Oestrogens (often these symptoms come after the menopause)
• Botulinum toxin A (blocks neuromuscular transmission - can cause urinary retention)

Question 41

What is neuromodulation and sacral nerve stimulation?

Answer 41

Continuous stimulation of the S3 nerve root via an implanted electrical pulse generator, improving the ability to suppress detrusor contractions

Question 42

What can cause acute urinary retention (inability to pass urine for >12h)?

Answer 42

Childbirth (epidural), perineal pain (herpes), surgery, anticholinergics

Question 43

What causes chronic urinary retention?

Answer 43

Urethral obstruction, detrusor inactivity, pelvic masses, autonomic neuropathies (diabetes)

Question 44

How can urinary retention be treated?

Answer 44

Catheterisation