Urogyne

Question 1

FDA approved Indications of sacral neuromodulation:

Answer 1

1- OAB
2- urge Urine incontinance
3- fecal incontinance

Question 2

Treatment of Recurrent UTI more than 4/ year

Answer 2

Nitrofurantoin

Question 3

Kelly’s suture is done in

Answer 3

Stress incontinence.

Question 4

The normal functional bladder capacity of a healthy human urinary bladder is approximately?

Answer 4

500ml
Thenormalfunctionalbladdercapacityisaround400‐600ml.Firsturgetovoidistypicallyfeltwhenthebladderisapproxiamtly150mlfull.

Question 5

The adjusted odds ratio for any incontinence associated with vaginal delivery compared with that with cesarean delivery was — (Rortveit, 2003a).

Answer 5

The adjusted odds ratio for any incontinence associated with vaginal delivery compared with that with cesarean delivery was 1.7 (Rortveit, 2003a).

Question 6

daughters of incontinent women had an increased relative risk of – and an absolute risk of– percent of having urinary incontinence. Younger sisters of incontinent women also had a greater likelihood of having any urinary incontinence (Hannestad, 2004).

Answer 6

daughters of incontinent women had an increased relative risk of 1.3 and an absolute risk of23 percent ofhaving urinary incontinence. Younger sisters of incontinent women also had a greater likelihood of having any urinary incontinence (Hannestad, 2004)

Question 7

Urine Continence requires the complex coordination of multiple components that include:

Answer 7

muscle contraction and relaxation, appropriate connective tissue support, and integrated innervation and communication between these structures. Simplistically, during filling, urethral contraction is coordinated with bladder relaxation and urine is stored. During voiding, the urethra relaxes and the bladder contracts. These mechanisms can be challenged by uninhibited detrusor contractions, marked increase in intraabdominal pressure, and degradation or dysfunction of the various anatomic components of the continence mechanism.

Question 8

Urogenital Sphincter Composed of striated muscle. this sphincter complex includes:

Answer 8

(1) the sphincter urethrea, (2) the urethro-vaginal sphincter and (3) the compressor urethrea.

Question 9

Function of a region of the rostral pons known as the pontine storage center (or “L” region) ?

Answer 9

region of the rostral pons known as the pontine storage center (or “L” region) also may increase activity of the external urethral sphincter.

Question 10

M2 and M3 receptor subtypes in bladder are predominantly responsible for

Answer 10

detrusor smooth muscle contraction. Thus, treatment with muscarinic antagonist medication blunts detrusor contraction to improve continence. Specifically, continence drugs that target only the M3 receptor maximize drug efficacy yet minimize activation of other muscarinic receptors and drug side effects.

Question 11

What is “M” region? Function ?

Answer 11

When an appropriate time for bladder emptying arises, sympathetic stimulation is reduced and parasympathetic stimulation is triggered via the pontine micturition center {or “M” region).

Question 12

Detrusor sphincter-dyssynergia

Answer 12

the urethral sphincter fails to relax during contraction of the detrusor and urine retention ensues. Classically, this is a possible urinary complication of spinal cord injury termed detrusor sphincter-dyssynergia and may lead to elevated bladder pressures and vesicoureteral reflux. Women with this condition are sometimes treated with alfa·blocking agents to help with sphincter relaxation and to lower bladder pressures during contraction, but these may aggravate hypotension.

Question 13

Physiology of urine evacuation

Answer 13

Efferent impulses from the pontine micturition center result in inhibition of somatic fibers in the Onuf nucleus and voluntary relaxation of the striated urogenital sphincter muscles. These efferent Impulses also result In preganglionic sympathetic Inhibition with opening of the vesical neck and parasympathetic stimulation, which results In detrusor muscarinic contraction. The net result Is relaxation of the striated urogenital sphincter complex causing decreased urethral pressure, followed almost Immediately by detrusor contraction and voiding.

Question 14

urethral and bladder neck support is integral to continence. This anatomic support derives from:

Answer 14

(1) ligaments along the urethra’s lateral aspects, termed the pubourethral ligament.
(2) the vagina and its lateral fascial condensation;
{3) the arcus tcndineus fascia pelvis;
(4) levator ani muscles.

Question 15

Detrusor overactivity (DO)

Answer 15

describes involuntary contractions of the bladder wall during filling cystometry. The contractions may be spontaneous or provoked and may or may not be associated with a sense of urgency or urgency incontinence. Because it is a urodynamies study finding, DO cannot be used interchangeably with the sympum descriptions overactive bladder urgency urinary incontinence. Nonetheless, DO is believed to underlie these last two. DO may be defined further by the qualifiers neurogenic (if a relevant neurologic condition is present) or idiopathic.

Question 16

impaired bladder muscle contractility may be a consequence of

Answer 16

aging, smooth muscle damage, fibrosis, hypoestrogenism, peripheral neuropathy (e.g., longstanding diabetes mellitus, vitamin B12 deficiency), or damage to spinal detrusor efferent nerves (e.g., multiple sclerosis or spinal stenosis)

Question 17

Voiding frequency is normally

Answer 17

less than eight times a day and once at night, and total volume voided in 24 hours is typically less than 1800 mL (Lukacz, 2009).

Question 18

frequent voiding without increased oral fluid intake may indicate

Answer 18

overactive bladder, UTI, calculi, or urethral pathology and often prompts additional evaluation. In addition, urinary frequency is commonly associated with interstitial cystitis/bladder pain syndrome (IC/BPS). With IC/BPS, the numbers of voids may commonly exceed 20 per day.

Question 19

Nocturia may be noted in women with

Answer 19

urgency urinary incontinence or in those with systemic fluid management disorders such as congestive heart failure. In the latter case, treatment of the underlying condition often leads to symptom improvement or cure of nighttime frequency.

Question 20

postvoid dribbling, is classically associated with

Answer 20

urethral diverticulum, which may often be mistaken for urinary incontinence

Question 21

urinary incontinence may be linked with several medical conditions or their treatments, which could be modified to improve incontinence. To help remember these potential contributors, a useful mnemonic is “DIAPPERS”

Answer 21

dementia/delirium, infection, atrophic vaginitis, psychological, pharmacologic, endocrine, restricted mobility, and stool impaction

Question 22

detrusor underactivity /impaired bladder muscle contractility may be a consequence of

Answer 22

aging, smooth muscle damage, fibrosis, hypoestrogenism, peripheral neuropathy (e.g., longstanding diabetes mellitus, vitamin B12 deficiency), or damage to spinal detrusor efferent nerves (e.g., multiple sclerosis or spinal stenosis) (Aldamanhori, 2017; Zimmern, 2014).

Question 23

Physical Examination General Inspection and Neurologic Evaluation of patient with urine incontinence

Answer 23

the perineum is inspected for evidence of atrophy, which may be noted throughout the lower genital tract. In addition, a suburethral cystic mass or dilation with transurethral expression of fluid during compression suggests a urethral diverticulum. Examination of an incontinent woman also includes a detailed neurologic evaluation of the perineum. Because neurologic responses may be altered in an anxious patient who is in a vulnerable examination setting, signs elicited during evaluation may not signify true pathology and are interpreted in context and with caution. We usually begin neurologic evaluation with an attempt to elicit a bulbospongiosus reflex, by stroking one labium majus with a cotton swab. Generally, both labia contract at the same time. The afferent limb of this reflex is the clitoral branch of the pudendal nerve, whereas its efferent limb is conducted through the inferior hemorrhoidal branch of the pudendal nerve. This reflex is integrated at the S2-S4 spinal cord level Thus, reflex absence may suggest central or peripheral neurologic deficits. Second, a normal circumferential anal sphincter contraction, colloquially called an anal wink, should follow cotton swab brushing of the perianal skin. External urethral sphincter activity requires at least some degree of intact S2-S4 innervation, and this anocutaneous reflex is mediated by the same spinal neurologic level. Thus, an absent wink may indicate deficits in this neurologic distribution.

Question 24

Lack of distal anterior vaginal wall support can lead to

Answer 24

urethral hypermobility during increased intraabdominal pressure. In patients with descent to the level of the hymen or beyond with Valsalva, urethral hypermobility is universal

Question 25

Simple cystometrics allows determination of

Answer 25

SUI and detrusor overactivity and measurement of first sensation, desire to void, and bladder capacity.however, is its inability to assess for ISD.

Question 26

A normal bladder capacity for most women ranges from — to — mL.

Answer 26

A normal bladder capacity for most women ranges from 300 to 700 mL.

Question 27

Multichannel cystometrics can evaluate for

Answer 27

ISD

Question 28

most patients can empty their bladder over – to – seconds with flow rates >– mL/s. Maximum flow rates < – mL/s, with a voided volume >— mL, are generally considered abnormally slow.

Answer 28

most patients can empty their bladder over 15 to 20 seconds with flow rates >20 mL/s. Maximum flow rates < 15 mL/s, with a voided volume >200 mL, are generally considered abnormally slow.

Question 29

Diagnosis of ISD (Intrinsic Sphincter Deficiency)

Answer 29

After cystometrography, once approximately 200 mL of saline has been instilled, an abdominal leak point pressure is measured. The patient is asked to perform a Valsalva maneuver, and the pressure generated by the effort is measured and evidence of urine leakage is sought. If leakage is seen when a pressure of <60 cmH20 is generated, criteria have been met for a diagnosis of iSD.

Question 30

A diagnosis of ISD is made if

Answer 30

the MUCP is <20 cmH20 or, if the leak point pressure is <60 cmH20

Question 31

Prognostic indicators that may predict a poor response to PFMT for SUI treatment include

Answer 31

severe baseline incontinence, prolapse beyond the hymenal ring, prior filled physiotherapy, history of prolonged second-stage labor, BMI >30 kg/m2, high psychological distress, and poor overall physical health

Question 32

Treatment of Stress Urinary Incontinence

Answer 32

• Pharma: For women with mixed urinary incontinence, a trial of imipramine can be considered to aid urethral contraction and closure. this tricyclic antidepressant has alfa adrenergic effects, and the urethra contains a high content of these receptors. However, the efficacy of this pharmacologic intervention may not be substantial, providing only mild symptomatic improvement.
• Surgery
• Pessary and Urethral Inserts

Question 33

rectoanal inhibitory reflex (RAIR) refers to

Answer 33

the transient relaxation of the lAS and contraction of EAS induced by rectal distention when stool first arrives in the rectum. this reflex is absent in those with congenital aganglionosis (Hirsclasprung disease) but preserved in patients with cauda equina lesions or after spinal cord transection (Bharucha, 2006).

Question 34

What urodynamic finding(s) are potentially associated with more marked degrees of stress incontinence?

Answer 34

Valsalva leak point pressures below 60 cm H2O, maximal urethral closure pressures below 20 cm H2O and an open bladder neck during filling all have been associated with more severe forms of stress incontinence.

Question 35

OAB symptoms triad

Answer 35

urinary urgency with or without urgency incontinence, frequency and nocturia

Question 36

The first-line approach to treatment of urgency incontinence is

Answer 36

behavioral modification, such as modulation of amount and timing of fluid intake as well as timed voiding.

Question 37

The most common perioperative complication of midurethral slings is

Answer 37

a postoperative urinary tract infection, which can be associated with approximately 30% of cases.

Question 38

In the bladder, M- receptors are more common than M- receptors (70–80% versus 20–30%).

Answer 38

In the bladder, M2 receptors are more common than M3 receptors (70–80% versus 20–30%).

Question 39

M- receptors are thought to be most responsible for initiating bladder contractility.

Answer 39

M3 receptors are thought to be most responsible for initiating bladder contractility.

Question 40

Management lines For patients with refractory overactive bladder syndrome (ie, who have failed conservative therapy or medical or anticholinergic therapy)

Answer 40

botulinum-A neurotoxin, peripheral tibial nerve stimulation, and sacral neuromodulation are treatment options.

Question 41

Initial treatment for urgency urinary incontinence

Answer 41

is conservative and can consist of bladder retraining such as timed voiding drills, urge inhibition, fluid restriction, and decreasing bladder irritants. Therapy with anticholinergics or β-agonists offers another appropriate first-line treatment option.

Question 42

conditions for which radiography may be reasonable include

Answer 42

acute or chronic cardiovascular or pulmonary disease, cancer, American Society of Anesthesiologist (ASA) status > 3, heavy smoking, immunosuppression, recent chest radiation therapy, and new emigration from areas with endemic pulmonary disease.

Question 43

First-line treatment of mesh erosion in case if TVT/TOT is

Answer 43

estrogen cream

Question 44

Indications for multichannel subtracted cystometry are:

Answer 44

complicated history; inconclusive single-channel studies; stress incontinence before surgical correction; urge incontinence not responsive to therapy; recurrent urinary loss after previous surgery for stress incontinence; frequency, urgency, and pain syndromes not responsive to therapy; nocturnal enuresis not responsive to therapy; lower urinary tract dysfunction after pelvic radiation or radical pelvic surgery; neurologic disorders; continuous leakage; suspected voiding difficulties.

Question 45

Blavais and Groutz created a nomogram based on several previous studies and defined bladder outlet obstruction as

Answer 45

the presence of a free Q max < 12 mL/s and P det of > 20 cm H2O in a pressure-flow study

Question 46

In OAB treatment warn patients that botulinum toxin therapy is associated with

Answer 46

limited duration of response, risk of urinary tract infections, and possible prolonged need for self-catheterization

Question 47

What is the advantage of abdominal sacrocolpopexy of Vaginal apical prolapse treatment over other vaginal approach procedures such as sacrospinous ligament or uterosacral ligaments suspensions ?

Answer 47

ASC maintains or lengthens the vagina in contrast to vaginal approach which may shorten it, also the use of synthetic mesh with multiple attachment sites to the vagina has very low risk of apical failure. Last unlike the vaginal approaches in which the vaginal apex is directly affixed to a structure, ASC repositions the vaginal apex to its nearly normal Anatomic position and remains mobile so lower dysparunia rates.

Question 48

Sympathetic Actions on Detrusor Muscle and Ganglia

Answer 48

-

Question 49

During physiologic bladder filling, little or no increase in intravesical pressure is observed, despite large increases in urine volume. This process, called ????????

Answer 49

This process, called accommodation, is caused primarily by passive elastic and viscoelastic properties of the smooth muscle and connective tissue of the bladder wall.

Question 50

Parasympathetic Actions on Detrusor Muscle

Answer 50

The chief neurotransmitter is cholinergic, with muscarinic receptors, and a second major neurotransmitter is noncholinergic and nonadrenergic. This observation accounts for detrusor atropine resistance.
In detrusor muscle, M2 and M3 predominate. While there are more detrusor M2 receptors, the M3 are more important for detrusor contractions. Dry mouth, slowed gastrointestinal motility, blurred vision, increased heart rate, heat intolerance, sedation with reductions in memory and attention, delirium, drowsiness, fatigue, and other cognitive functions are side effects related to the var- ious receptors located throughout the body.

Question 51

Smooth Muscle of Trigone and Urethra innervation

Answer 51

The innervation of the trigone smooth muscle fibers is an almost exclusively adrenergic innervation with chiefly α1 receptors. Choliner- gic development in the bladder is present at birth, whereas adrenergic development occurs later. Prostaglandins act as intracellular messengers to relax trigonal muscles.
The proximal urethral smooth muscle is rich in α-adrenergic receptors responsive to norepinephrine neu- rotransmitter. Acetylcholine, substance P, vasoactive intes- tinal polypeptide, and histamine are all additional potential transmitters in the urethra. Nitric oxide (NO) is promi- nent in the parasympathetic postganglionic innervation of the urethra, and exogenous NO or parasympathetic nerve stimulation relaxes urethral smooth muscle.

Question 52

Antimuscarinic medications should be avoided in patients with

Answer 52

narrow-angle glau- coma, impaired gastric emptying, or a history of urinary retention, and in patients taking oral potassium chloride supplements.

Question 53

Antimuscarinic medications should be avoided in patients with

Answer 53

narrow-angle glau- coma, impaired gastric emptying, or a history of urinary retention, and in patients taking oral potassium chloride supplements.

Question 54

nitrofurantoin carries a rare but real risk of ————————— in older adults and, therefore, would not be ideal in a patient with chronic obstruc- tive pulmonary disease.

Answer 54

nitrofurantoin carries a rare but real risk of chronic interstitial lung disease in older adults and, there- fore, would not be ideal in a patient with chronic obstruc- tive pulmonary disease.

Question 55

What is the best next treatment alternative for patient with recurrent UTI who developed a resistant urinary tract infection after 3 months of therapy with antibiotics

Answer 55

Methenamine salts have been shown to inhibit urinary tract infections by hydrolyzing in the urine (because of the acidity in the urine) into formaldehyde, which is bacteriostatic. As a result, there is no development of bacterial resistance to the medication. In order to optimize treatment and maximize urine acidity, methenamine is given together with vitamin C. Adverse effects include increased gastrointestinal acidity resulting in nausea or abdominal pain, as well as painful urina- tion and gross hematuria.