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SamerZ > Urogynecology > Flashcards

Urogynecology Flashcards

1
Q

How can the lower urinary tract symptoms be grouped?

A

Storage phase
voiding phase
Post-voiding phase

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2
Q

What are the definitions of daytime frequency and noctoria?

A

Daytime frequency: voiding more than 8 times per day and more than one time at night
Nocturia: having to wake up more than one time during the night to pass you on

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3
Q

What is the difference between terminal dribble and post void dribble?

A

Terminal dribble is a voiding symptom where dribbling starts before the urination is over while post void dribble happens after the urination is over and it is a post micturation symptom

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4
Q

What is the percentage of people affected with luts?

A

1/3 to 2/3

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5
Q

What is the most common form of urinary incontinence?

A

General population stress urinary incontinence
In elderly mixed urinary incontinents or urge urinary incontinence

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6
Q

Overactive bladder is a symptom rather than diagnosis differentiated between wet and dry. What are the criteria to name the symptom an overactive bladder?

A

Urgency, frequency and notoria.
This can be coupled with incontinence or not

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7
Q

What is the difference between sensory urgency and the detrusor overactivity?

A

Sensitive urgency is an overactive bladder with normal urodynamics
Detrusor overactivity has an abnormal urodynamic

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8
Q

What are the steps to take and the diagnosis of urinary incontinence?

A

First step always history
Second step physical exam (check pelvic floor muscle contractions before and after pelvic floor training)
Three investigation

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9
Q

What are the major investigations done in case of urinary incontinence?

A

Always start with urine dipstick (unless this is clearly a stress incontinence)
2- post void residual volume
3- symptom severity and quality of life assessment
4- bladder diaries for 3 days
5- finally urodynamics ( check flash cards regarding the step)
NB: pad testing and q-tip cystoscopy imaging are not being done anymore

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10
Q

What are the indications to perform urodynamics for patients with urinary incontinence?

A

Before surgery only in:
Urge-predominant urinary incontinence or urinary incontinence of unclear type
If symptoms are suggestive of voiding dysfunction
Anterior apical prolapse
History of previous surgery for stress incontinence

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11
Q

What are the indications for referral to a specialist service in case of urinary incontinence?

A
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12
Q

What are the lifestyle modification steps to do in case of urinary incontinence?

A

For overactive bladder:
1- decrease caffeine
2- modify fluid intake (less than 2 L)
3- decreasing weight if BMI more than 30

For stress urinary incontinence:
1- lose weight
2- decreased lifting

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13
Q

What are the other measures to do after initial lifestyle modification of stress urinary incontinence patients?

A

For stress urinary incontinence offer pelvic floor muscle training 8 /3/3 (a contractions perform three times per day for 3 months)
EMG not indicated
Continue exercise program if this was beneficial

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14
Q

What is the difference in pelvic muscle training. Between stress urinary incontinence and prolapse?

A

Stress urinary incontinence: 3 months
Prolapse: 4 months

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15
Q

If a patient presents with stress urinary incontinence and the initial exam showed a 4/5 pelvic muscle tone, what is the best next step in this management?

A

surgery is the best next step
Pelvic floor muscle training will not be helpful in this situation (every time the grade is four or five, we don’t use this modality)

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16
Q

Is electric simulation useful in the regular pelvic floor muscle training?

A

This modality is only useful in selected cases. Do not use in combination

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17
Q

When do we consider behavioral therapy not effective in urinary incontinence?

A

After 6 weeks as first line treatment for urge urinary incontinence and mixt urinary incontinence.
If no result within 6 weeks then go to medical treatment plus or minus training

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18
Q

Can we use neurostimulation to treat urge incontinence?

A

Do not offer percutaneous posterior tibial nerve stimulation although it is the least invasive
Offer only if:
Use it as the last resort
Woman doesn’t want Botox injections
After consulting MDT

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19
Q

What are the indications for the insertion of long-term and indwelling urethral catheter?

A

Chronic urinary retention
Skin wounds, pressure ulcers or irritations
Distressed and disruption
Or if the woman expresses preference

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20
Q

Important information before starting medical treatment for overactive bladder

A

Common adverse effect associate with the medicine
Dry mouth and constipation are the most common side effects
Result may not be visible before 4 weeks
Uncertain long term effect on cognitive function

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21
Q

What are the contraindications to use anti-colinergic medications?

A

Poor bladder emptying
Cognitive impairment or dementia
Use of other anticholinergic medications

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22
Q

What is the first medical option to use for overactive bladder?

A

OTD
Always start with Oocybutynin
If this treatment is effective but has a lot of side effect then offer the transdermal treatment

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23
Q

How to treat patients with neurologic disorder suffering from overactive bladder

A

Use Trospium instead of Ooxybutynin
O not for Old

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24
Q

Best treatment for nocturia

A

Desmopressin
Do not use with cystic fibrosis age more than 65 hypertension cardiovascular disease

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25
Q

When to recheck woman being treated for overactive bladder when the treatment is successful?

A

Initial follow up after 4 weeks of starting treatment. If treatment is successful then:
-If women ‘s age more than 75 recheck every 6 months
-If less than 75 yearly
If the treatment was not optimal shift medication and review patient again after 4 weeks

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26
Q

What should you do if the patient has tried medications for overactive bladder and they were not successful or tolerated?

A

Refer to secondary care to consider further treatment
If the treatment was working and then stopped working. Offer a face to face or telephone review

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27
Q

What do we do If OTD is not working?

A

Shift to mirabegron

28
Q

What is the next step?:
If patient with overactive bladder was started treatment on O, 4 weeks later symptoms are better but she has side effect

A

O transdermal

29
Q

What is the next step?
Patient was started on O for overactive bladder, then 4 weeks later no improvement:

A

Shift to T or D
Or O+T, O+D
Or any combination
Then recheck in 4 weeks

30
Q

What is the next step?
Patient was started on OTD for overactive bladder, symptoms improved and she reported minimum side effects?

A

Follow up in one year for less than 75 years old
Follow up in 6 months for more than 75 years old

31
Q

What are the options if overactive bladder medical treatment fails?

A

Botulinum toxin A
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion

32
Q

When botulinum toxin A is indicated, what is the dose administered, and how should we follow up?

A

100 IU by cysto
FU in 12 weeks
If not successful inject 200IU. If still no effect then discuss with MDT
If symptoms relief was adequate but did not last more than 6 months then consider adding the dose to 200 IU

33
Q

Step by step management of overactive bladder

A

1- midstream urine
2- bladder diary
3- remove caffeine
4- modify drinking habits
5- decrease weight of more than 30 BMI
6- bladder training for 6 weeks
7-Oxybutynin, Dariferacin, Toleterodine
8-Mirabegron
9-MTD and urodynamics
10-Bitulinum A injection
11-PSNS or PTNS (second line but less invasive)
12- augmentation cystoplasty
13- urinary diversion

34
Q

Surgical management of stress urinary incontinence

A

1- coloposuspension or 2) an autologous rectus fascia sling
3-intra-mural bulking agent
DO NOT OFFER routinely:
4-mid-urethral mesh sling procedures:
Retro pubic if any, not the top-down approach
5- artificial urinary sphincters

35
Q

After a stress urinary incontinous surgical management, when should we follow up on the patient?

A

After 6 months

36
Q

What is the next step of the surgical management of stress urinary incontinence failed after 6 months of follow-up?

A

Seek regional MDT advice
Consider medical treatment

37
Q

What is the medical treatment of stress urinary incontinence?

A

Duloxetine
To be used only in stress urinary incontinence and if surgical treatment is not suitable or not desirable

38
Q

Stress urinary incontinence stepwise approach

A

1-history based diagnosis
2- pelvic floor muscle tone test
3- weight loss
4- pelvic floor muscle exercise (8/3/3)
5-MDT review
6-colpo-suspension
7- surgically unfit = Duloxetine

39
Q

Mixed stress urinary incontinence stepwise approach

A

1- investigate + bladder diary/frequency volume chart
2- remove caffeine
3- modify drinking habits
4- weight loss FBI more than 30
5- bladder training for six weeks, PFME

40
Q

Mechanism of action of UroGyn drugs:

A
41
Q

POPQ test

A
42
Q

Pelvic organ prolapse staging:

A

Stage 0: normal
Stage 1: -3 to -1
Stage 2: -1 to +1
Stage 3: more than +1, not procidentia
Stage 4: procidentia

43
Q

Non-surgical management of pelvic organ prolapse

A

1- weight loss if her BMI more than 30
2- minimize heavy lifting
3- prevent and treat constipation

Then:
Pelvic floor muscle training for 16 weeks for stage 1 and 2

44
Q

When to use the estrogen ring in the case of pelvic organ prolapse

A

Pelvic organ prolapse+ vaginal atrophy+ cognitive impairment

45
Q

When to use pessaries in pelvic organ prolapse

A

If we have symptomatic prolapse and the patient is not clinically fit for surgery
When the risk of complication exists or the patient has physical or cognitive impairment offer an appointment and pessary clinic every 6 months

46
Q

Surgical procedures to use for uterine prolapse

A

Anterior prolapse: anterior repair
Posterior prolapse: posterior repair
Vault prolapse: abdominal sacro colpoplexy or sacro-spinous fixation

47
Q

How to treat mesh related complications?

A

If the erosion is less than 1 cm: estrogen cream and FU in 3 months
If erosion more than 1 cm: surgical removal

48
Q

Important timeframes in UroGyn

A

Bladder diary: 3 days
Bladder training: 6 weeks
Pelvic floor muscle training for stress incontinence: 12 weeks
Pelvic floor muscle training for prolapse: 16 weeks
Medicine review: 4 weeks

49
Q

When to recheck the patient
1-after the sling surgery
2-After augmentation cystoplasty, urinary diversions

A

1-6 months
2-Lifetime

50
Q

How to follow up post PTNS?

A

12 weeks sessions 30 minutes each
Follow up in 6 and 12 months

51
Q

Important points

A
52
Q

How to prevent vaginal vault prolapse?

A

Post vag. hysterectomy: McCall culdoplasty
Sacrospinous fixation: when the vault descends to the introitus during closure
Suturimg cardinal and utero sacral ligaments during TAH

53
Q

The sub-total hysterectomy or using permanent switches prevent vaginal vault prolapse?

A

No evidence to support this

54
Q

Comparison between abdominal sacrocolpopexy and sacrospinous fixation

A
55
Q

What is the best treatment for occult stress Urinary incontinence with vaginal vault prolapse?

A

Colposuspension + Sacrocolpopexy

56
Q

Best treatment for overt stress urinary incontinence in the setting of vaginal vault prolapse?

A

Mid- urethral sling surgery with sacrospinous fixation

57
Q

When we have prolapse and stress urinary incontinence, is it best to perform concomitant surgeries or interval surgeries?

A

It is always better to perform interval surgeries unless we have wall prolapse then concomitant surgery is preferred

58
Q

What is bladder pain syndrome?

A

It is an overactive bladder associated with pain lasting at least 6 months and getting better after voiding in the absence of other identifiable causes

59
Q

What are the main investigations to do in case of bladder pain syndrome?

A

Bladder diary
Food diary
Urine test to rule out infection
Urine cytology to rule out malignancy

60
Q

When are urodynamics and cystoscopy indicated in the bladder pain syndrome?

A

Urodynamics: when it’s not responding to treatment
Cystoscopy: to rule out other conditions

61
Q

What are the important steps in the diagnosis of a bladder pain syndrome?

A

1- history
2- urine dipstick and urine culture
3- physical exam
4- frequency volume charts

62
Q

Treatment of bladder pain syndrome

A

1- conservative: analgesia, dietary, exercise, pelvic muscle training, group, stress relief ( 3 to 6 months)
—IF FAILED: SECONDARY CARE
2- oral amitriptyline
—IF FAILED: MDT
3- intra vesicle DMSo, heparin, botulinum
4- neuromodulation
5- cystoscopy and hydrodistension

63
Q

What are the indications to use urodynamics?

A

1- In urge incontinence before invasive treatment
2- for stress urinary incontinence if surgical treatment failed, If associated with voiding the function or has anterior prolapse
3- in case of neurologic urinary incontinence
4- children with urinary incontinence before and after treatment
5- elderly with urinary incontinence after failed conservative management

64
Q

What are the normal cystometric finding?

A
65
Q

What are the things to check during a urodynamic study?

A

SamerZ (3 decks)

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