Urogyne Flashcards
Name the 3 types of pessaries
Support (Ring, Ring w diaphragm, Shaatz)
Space-occupying (Cube, donut, inflatoball, Gellhorn)
Incontinence (Ring w support and knob, incontinence ring, incontinence dish, Uresta device)
Name the predictors of pessary discontinuation (4)
Posterior wall prolapse
Younger age (< 65 yo)
Urinary incontinence
Discomfort
Which anticholinergic medication can be used with cholinesterase inhibitors (for Alzheimer’s disease)
Trospium (Trosec)
Name common complications of pessaries (3)
Increased discharge (physiologic)
Erosion (2-9 %)
Vaginal infections (2.5%) - BV, yeast
With which medication does Miragebron need a dose adjustment
Digoxin
(Also need to monitor digoxin levels more closely)
Name the 2 reasons that justify urologic work-up (cysto and imaging of upper urinary tract) in patients with UTIs
1- Infection by organisms not commonly causing UTIs
- Proteus
- Pseudomonas
- Enterobacter
- Klebsiella
2- Persistent hematuria after resolution of infection
What is the most common complaint of pessaries
Vaginal discharge
Which anticholinergic has the best efficacy to reduce norcturnal micturitions
Fesoterodine (Toviaz)
In addition:
- decreases nocturnal urgency episodes
- Improve subjective sleep quality
How is a UTI defined in terms of CFU (2)
1- > 100 000 CFU (10 ^5) /HPF
2- Symptoms of UTI + > 1000 CFU/ HPF
Which OAB medications are slective and non- selective M3 antagonists
Non-selective:
- Oxybutinin (Ditropan)
- Tolterodine (Detrol)
- Trospium (Trosec)
Selective: (SDF)
- Solifenacin (Vesicare)
- Darifenacin (Enablex)
- Fesoteridine (Toviaz)
Name the positive predictive factors for recurrent UTIs (5)
Symptoms after intercourse
Prior hx of pyelonephritis
Absence of nocturia
Prompt resolution of symptoms (48h) after initiation of treatment
Name common side effects of anticholinergics
Dry mouth
Constipation
What is the risk of re-operation for mesh exposure after transvaginal mesh placement
4-8%
Name the most common pathogens involved in recurrent UTIs
- E-coli (80%)
- S. Saprofyticus, Klebsiella pneumoniae, Proteus mirabilus (4%)
What are the presenting symptoms of vaginal mesh exposure (5)
Vaginal discharge
Vaginal bleeding
Pain
Dyspareunia
Partner’s discomfort w intercourse
(Often asymptomatic and found on exam)
Name the 2 medications linked to increased QT
Tolterodine (Detrol)
Solifenacin (Vesicare)
Which pessaries have the less chance of self care (3)
Gellhorn
Cube
Donut
What is a nomal PVR value
What is the % of urine emptied with a normal void
PVR: 100- 150 mL
75-80 % of total bladder volume
DDx of UTI (5)
- Chlamydia
- Gonorrhea
- HSV
- Vaginal yeast infection
- BV
Name the 5 components of urodynamic testing
1- Uroflowmetry
2- PVR
3- Bladder function
- Cystometry
- Pressure flow study
4- Urethral function tests (urethral pressure profile & abdominal leak point)
5- Electromyography
What is the treatment of a recurrent UTI within the first week post Tx
Urine C+S
Fluoroquinolone x 7 days
Norfloxacin, cipro, ofloxacin, fleroxacin
About UTIs which is more common between reinfection or relapse
Reinfection
Describe the “spil-over effect” of vaginal estrogens
Transcient increase in plasma estrogen levels at initiation of vaginal therapy secondary to decreased vaginal estrogen absorption in highly atrophied tissue. Resolves by 7-14 days max
Name the RFs for recurrent UTIs in pre-menopausal women (4)
Initial infection with e-coli
Dysfunctional voiding patterns (increased tone in the external sphincter during micturition)
Hx of UTIs before 15
Maternal hx of UTIs
What are the appropriate regimen for prevention of recurrent UTI in pregnancy (2)
Nitrofurantoin 50 mg
Cephalexin 250 mg
Either post-coital OR continuous
Which parameter of a UA is the most specific?
Nitrites (92-100%)
Followed by
Leukocyte esterase (41-86%)
Blood (42-46%)
What is the preferred surgical approach for mesh complications
Vaginal route
Abdominal or laparoscopic if vaginal fails
Name the 7 medications for OAB
Darifenacin (Enablex)
Solifenacin (Vesicare)
Fesoterodine (Toviaz)
Tolterodine tartrate (Detrol)
Trospium chloride (Trosec)
Mirabegron (Myrbitriq)
Oxybutinin (Ditropan)
What are the RF for mesh exposure (2)
Concomitant hysterectomy
Smoking
What are options for management of mesh complications
Conservative management
- Vaginal estrogen
- Pelvic floor physio
- NSAIDs, muscle relaxants, neuroleptics
Mesh revision
- Excision of exposed area
- Release of contracted/ tender arm of mesh
- Partial mesh excision
- Complete mesh excision
Define:
- UTI relapse
- UTI reinfection
UTI relapse :
- Recurrent infection with the same organism despite adequate therapy
UTI reinfection:
Recurrent UTI cause by:
- a different bacterial isolate OR
- previously isolated bacteria after (1) a negative culture OR (2) 2 weeks between infections
Name native tissue reconstructive techniques POP (4)
Anterior/ posterior colporrhaphy
McCall culdoplasty
Sacrospinous ligament suspension
Uterosacral ligament suspension
Mechanism of action of Abx to prevent recurrent UTI
1- Septra and Norfloxacin : decrease the rate of recovery of gram neg pathogens from fecal reservoir
2 - Nitrofurantoin: decreases recurrence by intermittently sterilizing the urine and possibly inhibiting bacterial attachment
Should you continue your mesh placement after:
1 - Bladder injury
2 - Rectal injury
Bladder injury:
Not enough evidence to suggest either way BUT small injuries could potentially be repaired and mesh placed (risk of fistula to be considered)
Rectal injury:
DO NOT place mesh
What is the risk (%) of mesh exposure AND
surgery in which compartment has the lowest risk of exposure
12 %
Anterior compartment
Name the predictors of unsuccessful pessary fitting (5)
Short vagina (< 6 cm)
Wide introitus (> 4 finger breadth)
Rectocele
Previous vaginal surgery
Coexisting SUI
Name the relative contraindications to anticholinergics (8)
Borderline or high PVR (Partial bladder outlet obstruction)
Controlled narrow-angle glaucoma
Impaired cognitive function
Reduced renal or hepatic function
Concomitant excessive alcohol use (adding sedative effects)
Decreased GI motility
Constipation
Myastenia gravis
Name the pessary used for cervical incompetance
Arabin pessary
How do you follow a UTI (symptomatic or asymptomatic) in pregnancy?
Test of cure 1 week post completion of therapy
Monthly follow-ups until end of pregnancy
Which anticholinergics is the safest in the elderly?
Fesoterodine (Toviaz)
Other options:
Tolterodine (Detrol) # 1
Solifenacin (Vesisare) # 2
Darifenacin #2
Trospium #3
Name the 5 complications that are increased in vaginal mesh repairs compared to native tissue repairs
Intraoperative bladder injury (increased 4 fold)
Bleeding > 500 mL
Post-operative hematoma
De novo stress incontinence
Non-sexual pain (vaginal, buttock, groin pain)
In what circumstances would you use a space occupying pessary in first intention?
Vaginal introitus width > 3-4 fingers
Name treatment options for refractory OAB
Botox (type A) detrusor injections
Central neurostimulation
Peripheral neurostimulation (sacral or tibial nerve)
Which type of vaginal mesh is associated with less complications
Polypropylene type 1 monofilament, macroporous synthetic mesh
What is the definition of recurrent UTI
2 uncomplicated UTIs in 6 months or 2-3 uncomplicated UTIs in 1 year
Mirabegron should be used with caution in what population
Patients with poorly controlled cardiovascular RF
Patients > 80 yo
Which pessaries allow for intercourse (2) and which ones should be removed (3)
Intercourse: Ring, Shaatz
Removal: Cube, donut, Gellhorn
Name the only life style modification that was shown to decrease recurrent UTIs
DC spermicide/ diaphragm use
What are the indications for UTI prophylaxis in pregnancy (3)
Pre-pregnancy hx of recurrent UTI
Persistent symptomatic or asymptomatic bacteriuria after 2 abx treatment
One UTI and RF for urinary complications (DM, sickle cell trait)
Name RFs for UTI in post-menopausal women (6)
Previous UTI
Incontinence
Pelvic floor prolapse
High PVR
Diabetes mellitus
Non secretors of histocompatibility blood-group AG
Mechanism of action of incontinence pessaries
Elevate and slightly constrict the urethra … which… Stabilize the urethra and increase urethral resistance
Describe the changes in the vaginal flora which pre-dispose to UTI in post-menopausal women
Decreased estrogen at menopause → thinning of vaginal epithelium + decrease amount of glycogen.
Environement now hostile to lactobacillus (protective as they prevent colonization by e-coli) → decrease # of lactobacillus → increase vaginal pH → increase risk of colinization with uropathogens
Name the factors predicting Septra resistance (4)
DM
Use of abx in the past 3-6 mo (no matter the reason)
Recent hospitalization
Recent TMP-SMX use
Name alternative measures to reduce recurrent UTIs (3+2)
Cranberries
Acupuncture
Estrogen in post-menopausal women
Probiotics (early evidence)
Intravaginal vaccine (ealy evidence)
Which anticholinergic can be used with other CYP450 inhibitors
Trospium (Trosec) - Level 3B
Name absolute contraindications to anticholinergics (5)
Urinary retention
Gastric retention
Uncontrolled narrow-angle glaucoma
Known hypersensitivity to the drugs
How does the vaginal pH change with menopause
Increases (less acidic = more basic)
Name the RF for UTIs in pre-menopausal women (3)
Frequent Intercourse
Spermicide
New sexual partners
Treatment of erosion from pessary
Remove pessary x 2-4 weeks
Vaginal estrogen (tabs or cream)
Change type or size of pessary
Biopsy (vaginal cancer) if persistant to r/o vaginal cancer
What are the 3 categories of symptoms linked to GUSM
1 - Urogenital atrophy
- Vaginal dryness
- Irritation
- Burning
- Dyspareunia
- Post coital bleeding
2- Lower urinary tract dysfunction
- Recurrent UTIs
- Urinary urgency
- Urinary frequency
- Nocturia
- Incontinence
- Dysuria
3- Sexual dysfunction
- Lack of lubrication
- Discomfort
- Pain
- Impaired function
- Arousal/ desire issues
Name 2 factors that would suggest an alternate dx then recurrent UTI
- Nocturia
- Persistence of symptoms between episodes of treated infection
Which anticholinergics are safe to use in cardiac patients (2)
Tolterodine (Detrol) # 1
Darifenacin (Enablex)
Treatment of increased physiological discharge with pessaries
Replens
Trimo-San cream
Name the potential complications of vaginal mesh surgery (8)
Infection
Bleeding
Organ injury + risk of fistula
Prolapse recurrence
Mesh exposure
Persistent pelvic pain
Dyspareunia
New incontinence symptoms
Name the 3 types of vaginal estrogens
Premarin cream 0.625 mg/g (Congugated equine estrogen)
Vagifem tabs 10 ug (micronized estradiol)
Estring ring (estradiol)
What are the 3 formulas for recurrent UTI treatment and
Name 2 options for recurrent UTI prophylaxis
Continuous prophylaxis
Post-coital single dose
Acute self treament
