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RC OBGYN (CG) > Urogyne > Flashcards

Urogyne Flashcards

1
Q

Name the 3 types of pessaries

A

Support (Ring, Ring w diaphragm, Shaatz)

Space-occupying (Cube, donut, inflatoball, Gellhorn)

Incontinence (Ring w support and knob, incontinence ring, incontinence dish, Uresta device)

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2
Q

Name the predictors of pessary discontinuation (4)

A

Posterior wall prolapse

Younger age (< 65 yo)

Urinary incontinence

Discomfort

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3
Q

Which anticholinergic medication can be used with cholinesterase inhibitors (for Alzheimer’s disease)

A

Trospium (Trosec)

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4
Q

Name common complications of pessaries (3)

A

Increased discharge (physiologic)

Erosion (2-9 %)

Vaginal infections (2.5%) - BV, yeast

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5
Q

With which medication does Miragebron need a dose adjustment

A

Digoxin

(Also need to monitor digoxin levels more closely)

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6
Q

Name the 2 reasons that justify urologic work-up (cysto and imaging of upper urinary tract) in patients with UTIs

A

1- Infection by organisms not commonly causing UTIs

  • Proteus
  • Pseudomonas
  • Enterobacter
  • Klebsiella

2- Persistent hematuria after resolution of infection

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7
Q

What is the most common complaint of pessaries

A

Vaginal discharge

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8
Q

Which anticholinergic has the best efficacy to reduce norcturnal micturitions

A

Fesoterodine (Toviaz)

In addition:

  • decreases nocturnal urgency episodes
  • Improve subjective sleep quality
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9
Q

How is a UTI defined in terms of CFU (2)

A

1- > 100 000 CFU (10 ^5) /HPF

2- Symptoms of UTI + > 1000 CFU/ HPF

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10
Q

Which OAB medications are slective and non- selective M3 antagonists

A

Non-selective:

  • Oxybutinin (Ditropan)
  • Tolterodine (Detrol)
  • Trospium (Trosec)

Selective: (SDF)

  • Solifenacin (Vesicare)
  • Darifenacin (Enablex)
  • Fesoteridine (Toviaz)
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11
Q

Name the positive predictive factors for recurrent UTIs (5)

A

Symptoms after intercourse

Prior hx of pyelonephritis

Absence of nocturia

Prompt resolution of symptoms (48h) after initiation of treatment

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12
Q

Name common side effects of anticholinergics

A

Dry mouth

Constipation

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13
Q

What is the risk of re-operation for mesh exposure after transvaginal mesh placement

A

4-8%

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14
Q

Name the most common pathogens involved in recurrent UTIs

A
  • E-coli (80%)
  • S. Saprofyticus, Klebsiella pneumoniae, Proteus mirabilus (4%)
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15
Q

What are the presenting symptoms of vaginal mesh exposure (5)

A

Vaginal discharge

Vaginal bleeding

Pain

Dyspareunia

Partner’s discomfort w intercourse

(Often asymptomatic and found on exam)

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16
Q

Name the 2 medications linked to increased QT

A

Tolterodine (Detrol)

Solifenacin (Vesicare)

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17
Q

Which pessaries have the less chance of self care (3)

A

Gellhorn

Cube

Donut

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18
Q

What is a nomal PVR value

What is the % of urine emptied with a normal void

A

PVR: 100- 150 mL

75-80 % of total bladder volume

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19
Q

DDx of UTI (5)

A
  • Chlamydia
  • Gonorrhea
  • HSV
  • Vaginal yeast infection
  • BV
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20
Q

Name the 5 components of urodynamic testing

A

1- Uroflowmetry

2- PVR

3- Bladder function

  • Cystometry
  • Pressure flow study

4- Urethral function tests (urethral pressure profile & abdominal leak point)

5- Electromyography

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21
Q

What is the treatment of a recurrent UTI within the first week post Tx

A

Urine C+S

Fluoroquinolone x 7 days

Norfloxacin, cipro, ofloxacin, fleroxacin

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22
Q

About UTIs which is more common between reinfection or relapse

A

Reinfection

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23
Q

Describe the “spil-over effect” of vaginal estrogens

A

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

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24
Q

Name the RFs for recurrent UTIs in pre-menopausal women (4)

A

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

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25
Q

What are the appropriate regimen for prevention of recurrent UTI in pregnancy (2)

A

Nitrofurantoin 50 mg

Cephalexin 250 mg

Either post-coital OR continuous

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26
Q

Which parameter of a UA is the most specific?

A

Nitrites (92-100%)

Followed by

Leukocyte esterase (41-86%)

Blood (42-46%)

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27
Q

What is the preferred surgical approach for mesh complications

A

Vaginal route

Abdominal or laparoscopic if vaginal fails

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28
Q

Name the 7 medications for OAB

A

Darifenacin (Enablex)

Solifenacin (Vesicare)

Fesoterodine (Toviaz)

Tolterodine tartrate (Detrol)

Trospium chloride (Trosec)

Mirabegron (Myrbitriq)

Oxybutinin (Ditropan)

29
Q

What are the RF for mesh exposure (2)

A

Concomitant hysterectomy

Smoking

30
Q
A
31
Q

What are options for management of mesh complications

A

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
32
Q

Define:

  • UTI relapse
  • UTI reinfection
A

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
33
Q

Name native tissue reconstructive techniques POP (4)

A

Anterior/ posterior colporrhaphy

McCall culdoplasty

Sacrospinous ligament suspension

Uterosacral ligament suspension

34
Q

Mechanism of action of Abx to prevent recurrent UTI

A

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

35
Q

Should you continue your mesh placement after:

1 - Bladder injury

2 - Rectal injury

A

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

36
Q

What is the risk (%) of mesh exposure AND

surgery in which compartment has the lowest risk of exposure

A

12 %

Anterior compartment

37
Q

Name the predictors of unsuccessful pessary fitting (5)

A

Short vagina (< 6 cm)

Wide introitus (> 4 finger breadth)

Rectocele

Previous vaginal surgery

Coexisting SUI

38
Q

Name the relative contraindications to anticholinergics (8)

A

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

39
Q

Name the pessary used for cervical incompetance

A

Arabin pessary

40
Q

How do you follow a UTI (symptomatic or asymptomatic) in pregnancy?

A

Test of cure 1 week post completion of therapy

Monthly follow-ups until end of pregnancy

41
Q

Which anticholinergics is the safest in the elderly?

A

Fesoterodine (Toviaz)

Other options:

Tolterodine (Detrol) # 1

Solifenacin (Vesisare) # 2

Darifenacin #2

Trospium #3

42
Q

Name the 5 complications that are increased in vaginal mesh repairs compared to native tissue repairs

A

Intraoperative bladder injury (increased 4 fold)

Bleeding > 500 mL

Post-operative hematoma

De novo stress incontinence

Non-sexual pain (vaginal, buttock, groin pain)

43
Q

In what circumstances would you use a space occupying pessary in first intention?

A

Vaginal introitus width > 3-4 fingers

44
Q

Name treatment options for refractory OAB

A

Botox (type A) detrusor injections

Central neurostimulation

Peripheral neurostimulation (sacral or tibial nerve)

45
Q

Which type of vaginal mesh is associated with less complications

A

Polypropylene type 1 monofilament, macroporous synthetic mesh

46
Q

What is the definition of recurrent UTI

A

2 uncomplicated UTIs in 6 months or 2-3 uncomplicated UTIs in 1 year

47
Q

Mirabegron should be used with caution in what population

A

Patients with poorly controlled cardiovascular RF

Patients > 80 yo

48
Q

Which pessaries allow for intercourse (2) and which ones should be removed (3)

A

Intercourse: Ring, Shaatz

Removal: Cube, donut, Gellhorn

49
Q

Name the only life style modification that was shown to decrease recurrent UTIs

A

DC spermicide/ diaphragm use

50
Q

What are the indications for UTI prophylaxis in pregnancy (3)

A

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)

51
Q

Name RFs for UTI in post-menopausal women (6)

A

Previous UTI

Incontinence

Pelvic floor prolapse

High PVR

Diabetes mellitus

Non secretors of histocompatibility blood-group AG

52
Q

Mechanism of action of incontinence pessaries

A

Elevate and slightly constrict the urethra … which… Stabilize the urethra and increase urethral resistance

53
Q

Describe the changes in the vaginal flora which pre-dispose to UTI in post-menopausal women

A

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

54
Q

Name the factors predicting Septra resistance (4)

A

DM

Use of abx in the past 3-6 mo (no matter the reason)

Recent hospitalization

Recent TMP-SMX use

55
Q

Name alternative measures to reduce recurrent UTIs (3+2)

A

Cranberries

Acupuncture

Estrogen in post-menopausal women

Probiotics (early evidence)

Intravaginal vaccine (ealy evidence)

56
Q

Which anticholinergic can be used with other CYP450 inhibitors

A

Trospium (Trosec) - Level 3B

57
Q

Name absolute contraindications to anticholinergics (5)

A

Urinary retention

Gastric retention

Uncontrolled narrow-angle glaucoma

Known hypersensitivity to the drugs

58
Q

How does the vaginal pH change with menopause

A

Increases (less acidic = more basic)

59
Q

Name the RF for UTIs in pre-menopausal women (3)

A

Frequent Intercourse

Spermicide

New sexual partners

60
Q

Treatment of erosion from pessary

A

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

61
Q

What are the 3 categories of symptoms linked to GUSM

A

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
62
Q
A
63
Q

Name 2 factors that would suggest an alternate dx then recurrent UTI

A
  • Nocturia
  • Persistence of symptoms between episodes of treated infection
64
Q

Which anticholinergics are safe to use in cardiac patients (2)

A

Tolterodine (Detrol) # 1

Darifenacin (Enablex)

65
Q

Treatment of increased physiological discharge with pessaries

A

Replens

Trimo-San cream

66
Q

Name the potential complications of vaginal mesh surgery (8)

A

Infection

Bleeding

Organ injury + risk of fistula

Prolapse recurrence

Mesh exposure

Persistent pelvic pain

Dyspareunia

New incontinence symptoms

67
Q

Name the 3 types of vaginal estrogens

A

Premarin cream 0.625 mg/g (Congugated equine estrogen)

Vagifem tabs 10 ug (micronized estradiol)

Estring ring (estradiol)

68
Q

What are the 3 formulas for recurrent UTI treatment and

Name 2 options for recurrent UTI prophylaxis

A

Continuous prophylaxis

Post-coital single dose

Acute self treament

RC OBGYN (CG) (13 decks)

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