Urogynaecology (Forest notes)

Question 1

What would you expect to see on cystometry in…
Stress incontinence?
OAB?
Multiple sclerosis?

Answer 1

Stress incontinence? leakage on coughing with increase abdominal pressure and absence of detrusor activityu
OAB? involuntary detrusor contraction
Multiple sclerosis? gradual rise in detrusor with water filling - low compliance/loss of elasticity

Question 2

1st line management in urinary incontinence?

Answer 2

lifestyle, weight loss, caffeine, supervised pelvic floor training (3 months).

Question 3

Why is a post-void residual helpful?

Answer 3

If high PV residual + frequency suggests unable to empty bladder fully&raquo_space; overflow incontinence
If you start anti-cholinergic medications then they will go into retention!

Question 4

When are urodynamics useful?

Answer 4

Urge incontinence, overactive bladder.
Not SI

Question 5

When should you be suspicious of overflow incontinence?

Answer 5

After surgery or delivery - abdominal mass and pain

Question 6

OAB - 1st line? 2nd line?

Answer 6

OAB
1st line - anti-cholinergics (oxybutynin)
2nd line - beta 3 adrenergic agonist (mirabegron)
3rd line - MDT then bladder wall botox (double dose of 200units if neurogenic e.g. MS)
sacral nerve stimulator (80% success)
posterior tibial nerve stimulator (70% success)

Question 7

Name the main anti-cholinergics and things to be aware of

Answer 7

Oxybutynin - causes confusion in over 80s, can use patch if can’t take PO
Tolteridone - fine in oldies, twice daily dosing
Darifenacin - highly selective single dosing

Question 8

Side effects anti-cholinergics?

Answer 8

dry eyes and mouth, constipation

Question 9

Contraindications to anti-cholinergics?

Answer 9

UC, narrow angle glaucoma, myaesthenia gravis - DO NOT GIVE

Question 10

When should you follow up after starting meds?

Answer 10

4 weeks

Question 11

On cystometry, how do you calculate detrusor pressure?

Answer 11

Bladder pressure minus abdominal pressure (measured by rectal probe)

Question 12

What are the issues with sacral nerve stimulators?

Answer 12

jolting/shocks, pain, infection, change in bowel habit

Question 13

What medicine for nocturia?

Answer 13

desmopressin

Question 14

Interventions for stress incontinence?

Answer 14

1st line: Colposuspension, autologous rectus fascial sling
2nd line: bulkamid injections (but less effective and wear off over time)

Question 15

How many days of bladder diary needed?

Answer 15

3

Question 16

Who is desmopressin contraindicated in?

Answer 16

CF, >65 with HTN/CVD

Question 17

When can duloextine be used?

Answer 17

For stress incontinence when women prefer non-surgical treatment or are not suitable for surgery

Question 18

When is vaginal oestrogen useful in incontinence?

Answer 18

Vaginal atrophy and OAB

Question 19

What’s a micturating cystourethrograph?

Answer 19

X-ray imaging whilst weeing with contrast dye

Question 20

What demonstrates stress incontinence on a micturating cystouterthrograph?

Answer 20

Loss of urethrovesical angle, SHOULD be >100 degrees in continent women.
180 degrees (straight line) is type 3 - no angle keeping urethra up and closed so it drops down by 2-3cm

Question 21

What is normal flow rate on uroflowmetry?

Answer 21

> 15ml/s
Need to pass 150mls to interpret, normal shaped is bell curved.

Question 22

Side effects of duloxetine?

Answer 22

Dry mouth, nausea, decreased libido, SUICIDAL thoughts

Question 23

Do NOT offer..

Answer 23

Marshall Marchetti Kranitz
Mesh slings not offered routinely.

Question 24

If a patient presents with a vaginal bulge after a burch colposuspension, what is it likely to be?

Answer 24

Enterocoele

Question 25

Draw out a POPQ table
+ normal values

Answer 25

Aa ant wall area A | Ba ant wall area B | C Cervix
-3 -3 -8

gh - midurethra | pb 3-4cm | TVL 8-10cm
to post hymen
2-3cm

Ap post wall area A | Bp post wall area B | D post fornix
-3 -3 -10

Question 26

Define Area A?

Answer 26

3cm above hymen, so max value is +3 or -3

Question 27

Middle row are…

Answer 27

fixed entities and not useful in diagnosis

Question 28

Stage 1 prolapse?

Answer 28

Leading edge is less than -1

Question 29

Stage 2 prolapse

Answer 29

Leading edge is ≥ -1 but <+1cm

Question 30

Stage 3 prolapse?

Answer 30

Leading edge is +1 to +5cm

Question 31

Stage 4 prolapse?

Answer 31

Leading edge is >5cm

Question 32

What is bladder pain syndrome AKA?

Answer 32

Interstitial cystitis
It is a diagnosis of exclusion

Question 33

Sx of bladder pain syndrome?

Answer 33

pain, pressure discomfort, pain during filling, frequency or urgency
Has to occur for >6 weeks without UTI

Question 34

Prevalence of bladder pain syndrome?

Answer 34

2.6%, women>men

Question 35

Initial investigations for bladder pain syndrome?

Answer 35

Bladder diary, urine dip
Consider food diary and urine cytology

Question 36

Conservative treatments bladder pain syndrome?

Answer 36

avoid caffeine, alcohol, acidic foods
stress management, exercise
analgesia

Question 37

Pharmacological treatments bladder pain syndrome?

Answer 37

amitriptylline
cimetidine

Question 38

Other specialised treatments for bladder pain syndrome?

Answer 38

Intravesical lidocaine, hyaluronic acid, DMSO

Question 39

What might be seen at cystoscopy in bladder pain syndrome?

Answer 39

Hunner’s lesions

Question 40

Complications of SSF for vault prolapse

Answer 40

Anterior prolapse
SUI
Buttock pain