Urogynaecology and Prolapse

Question 1

Risk factors for Stress Urinary Incontinence?

Answer 1

Question 2

Stress incontinence is associated with laxity of the supporting structures of the pelvic floor, particularly the _________________________

Answer 2

Stress incontinence is associated with laxity of the supporting structures of the pelvic floor, particularly the pubourethral ligament

Question 3

Investigations for Urinary Incontinence?

Answer 3

Urinalysis – dipstick and MSU to exclude urinary tract infection and glycosuria (diabetic polyuria)

Frequency volume chart (bladder diary)

Urodynamics

Question 4

Management of Stress Urinary Incontinence?

Answer 4

Basic:
* Weight Loss
* Treatment of Cough
* Pessary
* Pelvic floor Exersises

Surgical Management:
* Periurethral Injections
* Tension-free vaginal tape (TVT)
* Biological Sling

Question 5

Management of Overactive Bladder Syndrome (Urge Incontinence)

Answer 5

Lifestyle advice – reduce fluid consumption to 1.5-2L per day; avoid caffeine (caffeine is a diuretic and a direct stimulant of the detrusor), alcohol, soda and juices

Bladder retraining – involves practice of suppressing urinary urge, extending the intervals between voiding, and increasing these intervals in increments

Anticholinergic (antimuscarinic) - Oxybutynin
* MOA – block parasympathetic input to the bladder, thus relaxing the detrusor muscle

Beta-agonists - Mirabegron
* MOA- Acts on Beta-3 Receptor of the bladder resulting in relaxation of the detrusor

Vaginal Oestrogen (Post-Menopausal)

Botulinum toxin A: may be injected into the detrusor cystoscopically; the procedure is repeated every 6-12 months; efficacy of up to 90%; may be complicated by urinary retention (5-10%), which is treated with intermittent self-catheterisation

Neuromodulation

Question 6

General symptoms of Prolapse?

Answer 6

dragging sensation, discomfort, heaviness in the pelvis, feeling of a ‘lump coming down’, backache, dyspareunia, difficulty inserting tampons; symptoms generally get progressively worse over the day

Cysto-urethrocele– urinary urgency or frequency, incomplete bladder emptying, urinary retention

Rectocele – constipation, difficulty with defaecation; the prolapse may require digital reduction to defaecate

Question 7

Measuring of Pelvic Organ Prolapse?

Answer 7

First degree – lowest part of prolapse descends halfway down vaginal axis toward introitus

Second degree – lowest part of prolapse extends to introitus, and through introitus on straining

Third degree – lowest part of prolapse extends through introitus and lies outside the vagina

Fourth degree – vaginal eversion is complete

Question 8

Conservative Management of Pelvic Organ Prolapse?

Answer 8

Pelvic floor muscle exercises

Intravaginal devices (pessaries)

Question 9

Surgical Options for Uterine prolapse?

Answer 9

Hysteropexy
* Abdominal- Sacrohysteropexy (open or laparoscopic) approach; uterus and cervix are attached to the sacrum with a bifurcated non-absorbable mesh
* Vaginal approach- Sacrospinous hysteropexy; uterus and cervix are attached to the sacrospinous ligament using permanent or dissolvable sutures.

Manchester repair

Hysterectomy

Question 10

Surgical Options for Vaginal Vault Prolapse?

Answer 10

Vaginal route –Sacrospinous vault fixation

Abdominal route (open or laparoscopic) – Sacrocolpopexy

Question 11

Surgical Options for Cystocele (anterior defect)?

Answer 11

Vaginal route – anterior colporrhaphy (or anterior repair)

Abdominal route (open or laparoscopic) – paravaginal repair, sacrocolpopexy

Question 12

Surgical options for Posterior defect (rectocele or enterocele)

Answer 12

Vaginal route:
* posterior colporrhaphy (or posterior repair)
* perineal body reconstruction (or perineoplasty)

Abdominal route (open or laparoscopic): sacrocolpopexy

Question 13

What is an Anterior colporrhaphy (or anterior repair)?

Answer 13

Used to repair Cysto-Urethrocele (Vaginal Approach)

Procedure – the anterior vaginal wall is buttressed by sutures to the surrounding fascia, and excess vaginal tissue is excised

Question 14

What is an Posterior colpoperineorrhaphy (posterior repair)?

Answer 14

Used to repair Rectocele, Enterocele (Vaginal Approach)

Procedure – the posterior vaginal wall is buttressed by sutures to the surrounding fascia, and excess vaginal tissue is excised; perineoplasty is performed by placing deeper sutures into the perineal muscles to provide additional support

Question 15

What is Hysteropexy?

Answer 15

Used to repair Uterine Prolapse

Abdominal- Sacrohysteropexy (open or laparoscopic); the uterus and cervix are attached to the sacrum with a bifurcated non-absorbable mesh

Vaginal approach- Sacrospinous hysteropexy; the uterus and cervix are attached to the sacrospinous ligament using permanent or dissolvable sutures