Urogynaecolpgy Flashcards
What type of disease is cystocele?
Pelvic organ prolapse
Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
Epidemiology of pelvic floor disorders
20% of adult women experience regular incontinence
10% will have surgery for prolapse
< 10% anal incontinence
Increase with age, parity, obesity, smoking…
What is cystocele caused by?
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
What is prolapse of both the bladder and the urethra?
Cystourethrocele
What are the risk factors for cystocele?
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Presentation of cystocele?
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
- Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves.
How do we examine for cystocele?
patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.
Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele
women can be asked to cough or “bear down” to assess the full descent of the prolapse.
What are the grades of uterine prolapse using the pelvic organ prolapse quantification (POP-Q) system?
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
What is the conservative management for Cystocele?
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
When is conservative management used for cystocele?
Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery
How can a vaginal pessary help with cystocele?
Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems.
What are the different types of pessaries?
- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
- Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
- Cube pessaries are a cube shape
- Donut pessaries consist of a thick ring, similar to a doughnut
- Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
How can surgery help with cystocele?
definitive option for treating a pelvic organ prolapse. It is essential to consider the risks and benefits of any operation for each individual, taking into account any co-morbidities. There are many methods for surgical correction of a prolapse, including hysterectomy.
What are the possible complications of pelvic organ prolapse surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
What is the definition of Pelvic organ prolapse?
● Herniation of one more pelvic organ into the vagina.
What is the normal anatomy of the pelvis?
- Level 1 support:
- Uterosacral ligaments - extend posteriorly from cervix / upper vagina to the sacral spine.
- Level 2 support:
- Arcus tendineus fasciae pelvis (ATFP) - runs from ischial spines to pubic tubercle, attaching to
sheets of suspensory ‘slings’ of fascial tissue e.g. pubovesicocervical fascia. - Level 3 support:
- Perineal body - fibromuscular mass, point of attachment for pelvic muscles.
- Pubourethral ligaments.
- Pelvic floor - (levator ani and coccygeus muscles).
What is the pathophysiology by type?
- Uterosacral ligament weakness - uterine prolapse
- ATFP weakness - cystocele, rectocele
- Pubourethral ligament weakness - urethrocele
What is the aetiology of pelvic organ prolapse?
● Loss of sufficient support for pelvic organs due to multiple factors including pregnancy,
vaginal delivery and pelvic surgery.
What are the risk factors for pelvic organ prolapse?
- Vaginal delivery (risk increased with increasing parity) - damage to nerves, muscles and
fascia - Increasing age - reduced elasticity of connective tissue
- High BMI - raised intra-abdominal pressure
What are the types of pelvic organ prolapse?
- Uterine prolapse - descent of cervix +/- uterus into the vagina.
- Urethrocele - prolapse of the urethra into anterior vaginal wall.
- Cystocele - prolapse of bladder into anterior vaginal wall.
- Rectocele - prolapse of rectum into posterior vaginal wall.
- Enterocele - prolapse of the small bowel through the Pouch of Douglas into the posterior
vault of the vagina.
What are the signs of pelvic organ prolapse?
are seen on speculum examination:
○ Uterine - descended cervix / uterus
○ Vaginal (urethrocele, cystocele, rectocele, enterocele) - protrusion into vaginal
vault anteriorly, anteriorly, posteriorly, posteriorly respectively.
What are the symptoms of different types of pelvic organ prolapse?
○ Uterine - vaginal pressure, dyspareunia, feeling of something descending into the
vagina.
○ Urethrocele - stress incontinence.
○ Cystocele - recurrent UTI, difficulty passing urine.
○ Rectocele - difficulty defecating.
○ Enterocele - dragging sensation.
What are the investigations for pelvic organ prolapse?
● Typically diagnosed clinically based on characteristic symptoms and signs.
What are the conservative management options for pelvic organ prolapse?
○ Pelvic floor exercises.
○ Avoidance of triggers e.g. heavy lifting, straining in constipation.
○ Weight loss, if overweight.
○ Topical oestrogen (counteracts urogenital atrophy - see Menopause).
○ Pessaries
What are some surgical options for pelvic organ prolapse?
○ Uterine - options include hysterectomy, sacro-hysteropexy (mesh), Manchester
repair.
○ Vaginal vault - options include sacrospinous fixation, sacro-colpopexy (mesh).
History, examination, investigations and treatment for utero-vaginal prolapse?
History
‘SCD’ Lump, discomfort, pelvic floor & sexual dysfunction
Examination
Bimanual & Sims speculum
Investigations
Usually none
Treatment
Reassurance & advice, treat pelvic floor symptoms, pessary, surgery
What are the types of vaginal pessaries
Shelf
Ring
Gellhorn
When do we repair prolapse?
Symptomatic
(dyspareunia, discomfort, obstruction, bothersome)
Severe
(outside vagina, ulcerated, failed conservative measures)
What is the definition of urinary incontinence?
● Involuntary passage of urine.
How do we assess incontinence in women
Symptoms and investigations
What is urinary continence and what are the two types?
Urinary incontinence refers to the loss of control of urination. There are two types of urinary incontinence, urge incontinence and stress incontinence
What is urge incontinence and what is it caused by?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder
What is the pathophysiology of urge incontinence?
○ Mechanism not fully understood - likely a combination of myopathy and
neuropathy.
Involuntary bladder contractions
Sphincter weakness
Overactive bladder
Stress urinary incontinence
Typical description of urge incontinence
suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs
What is the pelvic floor and what does it consist of?
pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis
What is stress incontinence caused by?
weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.
Urinary loss during a period of raised intra-abdominal pressure, e.g coughing and sneezing
What is the pathophysiology of stress incontinence?
○ Raised intra-abdominal pressure increases intra-vesical pressure.
○ IVP exceeds resistance of urethral sphincters leading to leakage.
○ This typically occurs due to downward movement of the internal sphincter
secondary to pelvic floor weakness (urethral hypermobility).
What does stress incontinence involve?
Involuntary leakage
Cough
Laugh
Lifting
Exercise
Movement
Walking / running downhill
Intercourse
Stumble / choking / vomiting
What is mixed
weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.
What is the pathophysiology behind the different types of incontinence?
Sphincter Weakness: Stress Incontinence
Detrusor Overactivity: Overactive Bladder
(Mixed Incontinence = both)
Fistula
Neurological & Functional
Overflow & retention
What is mixed incontinence?
Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.
What is overflow incontinence?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine
Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine
What can cause overflow incontinence
with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.
What is overflow incontinence more common in?
more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management
What are the risk factors for urinary incontinence?
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
High parity
What is the presentation of stress and urge incontinence?
● Stress incontinence - involuntary passage of urine during activities that raise
intra-abdominal pressure (sneezing, coughing etc.)
● Urge incontinence - involuntary passage of urine with associated urge to pass urine,
increased urinary frequency
What are the investigations for urinary incontinence?
● First Line: urinalysis to rule out UTI, plus:
○ Bladder diary
○ Symptom questionnaire
● Second Line: urinary stress testing, e.g.
○ Cough stress test
○ Empty supine stress test
Urinalysis (MSU)
Frequency volume chart (FVC)
Residual urine measurement (RU)
Questionnaire (ePAQ)
How do we measure residual urine measurement?
- In & out catheter - CISC
- Post surgical voiding dysfunction, post natal retention, neuropath
- US
What questions and domains are asked about in the EPAQ?
Urinary:
Pain
Voiding
Overactive bladder
Stress incontinence
Quality of life
Vaginal:
Pain
Capacity
Prolapse
Quality of life
Bowel
IBS
Constipation
Evacuation
Continence
Quality of life
Sexual
Urinary
Bowel
Vaginal
Dyspareunia
Overall sex life
How can a medical history differentiate between types of urinary incontinence?
urinary leakage with coughing or sneezing (stress incontinence), and incontinence due to a sudden urge to pass urine with loss of control on the way to the toilet (urge incontinence).
What are the modifiable lifestyle factors that contribute to symptoms of urinary incontinence?
Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)
Weight loss1
Smoking cessation2
Reduced caffeine intake3
Avoidance of straining and constipation4
How do we assess the severity of urinary incontinence?
- Frequency of urination
- Frequency of incontinence
- Nighttime urination
- Use of pads and changes of clothing
What should an examination of urinary incontinence examine for?
Assess pelvic tone
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
During the examination, ask the patient to cough and watch for leakage from the urethra.
how strength of the pelvic muscle contractions be examined?
During a bimanual examination by asking the woman to squeeze against the examining fingers - graded by the modified Oxford grading system
modified Oxford grading system
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
How can we investigate urinary incontinence?
A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology.
Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
What are urodynamic tests used for and what needs to be stopped when doing one?
Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.
What do urodynamic tests measure?
Cystometry measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
Post-void residual bladder volume tests for incomplete emptying of the bladder
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Management of stress incontinence
○ First Line: pelvic floor exercises (8 contractions x3 per day) + lifestyle measures
e.g. reducing caffeine, weight loss, moderate fluid intake.
○ Second Line: (for some patients) - pseudoephedrine, topical oestrogen
○ Third Line: surgery such as retropubic colposuspension
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel.
What are the surgical options to treat stress incontinence include?
- Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
- Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape
- Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support
What is the management of Urge incontinence?
○ First Line: bladder training
○ Second Line: anticholinergic e.g. oxybutynin, solifenacin
○ Third Line: mirabegron (beta-3 agonist)
○ Plus: topical oestrogen if atrophic vaginitis present
What are some SE of anticholinergic medications?
dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia
What are the features of the detrusor and overactive bladder muscles?
Detrusor
Smooth muscle, transitional epithelium
Normally contracts only during micturition
Overactive bladder
Involuntary detrusor contractions
Reflex bladder activity
Urgency, urgency incontinence
What is the innervation, neurotransmitters, receptors and antagonists for detrusor and overactive bladder?
Innervation
Sacral Parasympathetic
Neurotransmitter
Acetylcholine
Receptors
Muscarinic: M2 & M3
Antagonsists
Atropine (Oxybutynin, Tolterodine, Solifenacin, Trospium)
What does muscarine do?
Mimics effect of acetyl choline at muscarinic receptors
What is muscarine poisoning characterised by?
Increased salivation
Excessive sweating & lacrimation
Followed by…
Abdominal pain, severe nausea, diarrhoea, blurred vision & laboured breathing.
Death may result from cardiac or respiratory failure
The specific antidote is atropine
What are the side effects of atropine use?
Dry cracked tongue
Diarrhoea
Blurred vision
Cognitive impairment
Tachycardia
What are anticholinergics?
Atropine-like agents (Antimuscarinics)M2 & M3 Receptor Antagonists
Eg Oxybutynin
Features of oxybutynin
2.5 - 5mg bd - tds
60 - 90% side effects Dry mouth, blurred vision
Drowsiness, Constipation
7% “cured” after one year
Large placebo effect
Care in elderly
PRN as effective, less side effects (Burton 1994)
Examples of anticholinergics
Tolterodine
Propiverine
Trospium
Solifenacin
What is the mechanism of action of mirabegron?
Mechanism of Action
Beta-3 adrenergic receptor agonist
Relaxes smooth muscle detrusor
Increases bladder capacity
What is clostridium botulinum?
Gram +ve spore bearing, obligate anaerobe
What conservative treatment is good for stress incontinence?
Self-help & Lifestyle adaptation:
Weight, smoking, oestrogen
Physiotherapy: Pelvic Floor Exercises
Success rate up to 60%
Advocated prior to surgery in all cases
Surgery: Colposuspension or Sling
May be unsuitable…
Medical conditions
Mild or intermittent symptoms
Personal circumstances
What does physiotherapy consist of?
Combinations of….
Pelvic floor exercises
Biofeedback
Electrical stimulation
Vaginal cones
What is involved in physiotherapy - PFE?
Pelvic floor muscle contraction
>
Clamping / compression of urethra
>
Increased urethral pressure
>
Reduced leakage
When do we do surgery for stress incontinence?
Principles
Restore pressure transmission to urethra
Support / elevate urethra
Increase urethral resistance
