Urogynaecology (Forest notes) Flashcards
What would you expect to see on cystometry in…
Stress incontinence?
OAB?
Multiple sclerosis?
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
1st line management in urinary incontinence?
lifestyle, weight loss, caffeine, supervised pelvic floor training (3 months).
Why is a post-void residual helpful?
If high PV residual + frequency suggests unable to empty bladder fully»_space; overflow incontinence
If you start anti-cholinergic medications then they will go into retention!
When are urodynamics useful?
Urge incontinence, overactive bladder.
Not SI
When should you be suspicious of overflow incontinence?
After surgery or delivery - abdominal mass and pain
OAB - 1st line? 2nd line?
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)
Name the main anti-cholinergics and things to be aware of
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
Side effects anti-cholinergics?
dry eyes and mouth, constipation
Contraindications to anti-cholinergics?
UC, narrow angle glaucoma, myaesthenia gravis - DO NOT GIVE
When should you follow up after starting meds?
4 weeks
On cystometry, how do you calculate detrusor pressure?
Bladder pressure minus abdominal pressure (measured by rectal probe)
What are the issues with sacral nerve stimulators?
jolting/shocks, pain, infection, change in bowel habit
What medicine for nocturia?
desmopressin
Interventions for stress incontinence?
1st line: Colposuspension, autologous rectus fascial sling
2nd line: bulkamid injections (but less effective and wear off over time)
CBD : colp >bulk>dulox
How many days of bladder diary needed?
3
Who is desmopressin contraindicated in?
CF, >65 with HTN/CVD
When can duloextine be used?
For stress incontinence when women prefer non-surgical treatment or are not suitable for surgery
When is vaginal oestrogen useful in incontinence?
Vaginal atrophy and OAB
What’s a micturating cystourethrograph?
X-ray imaging whilst weeing with contrast dye
What demonstrates stress incontinence on a micturating cystouterthrograph?
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
What is normal flow rate on uroflowmetry?
> 15ml/s
Need to pass 150mls to interpret, normal shaped is bell curved.
Side effects of duloxetine?
Dry mouth, nausea, decreased libido, SUICIDAL thoughts
Do NOT offer..
Marshall Marchetti Kranitz (sutures which correct urethrovesical angle)
Mesh slings not offered routinely.
If a patient presents with a vaginal bulge after a burch colposuspension, what is it likely to be?
Enterocoele
Draw out a POPQ table
+ normal values
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
Define Area A?
3cm above hymen, so max value is +3 or -3
Middle row are…
fixed entities and not useful in diagnosis
Stage 1 prolapse?
Leading edge is less than -1
Stage 2 prolapse
Leading edge is ≥ -1 but <+1cm
Stage 3 prolapse?
Leading edge is +1 to +5cm
Stage 4 prolapse?
Leading edge is >5cm
What is bladder pain syndrome AKA?
Interstitial cystitis
It is a diagnosis of exclusion
Sx of bladder pain syndrome?
pain, pressure discomfort, pain during filling, frequency or urgency
Has to occur for >6 weeks without UTI
Prevalence of bladder pain syndrome?
2.6%, women>men
Initial investigations for bladder pain syndrome?
Bladder diary, urine dip
Consider food diary and urine cytology
Conservative treatments bladder pain syndrome?
avoid caffeine, alcohol, acidic foods
stress management, exercise
analgesia
Pharmacological treatments bladder pain syndrome?
amitriptylline
cimetidine
Other specialised treatments for bladder pain syndrome?
Intravesical lidocaine, hyaluronic acid, DMSO
What might be seen at cystoscopy in bladder pain syndrome?
Hunner’s lesions
Glomerulation - haemorrhagic spots and granulation
Complications of SSF for vault prolapse
Anterior prolapse
SUI
Buttock pain
