Urogynecology Flashcards
Define anterior compartment prolapse
Herniation of anterior vaginal wall
Cystocele: backward descent of the urinary bladder into vagina and beyond
Urethrocele: backward descent of urethra into vagina and beyond
Define posterior compartment prolapse
- Herniation of posterior vaginal wall
- Rectocele: forward descent of the rectum into vagina and beyond
Define apical compartment prolapse
Herniation of the apex of the vagina into the lower vagina, to the hymen or beyond the vaginal introitus
Apex can be either the uterus and cervix, cervix alone or vaginal vault
Enterocele: herniation of the pouch of Douglas which contains loops of intestines through the upper part of vagina
Uterine prolapse: downward displacement of uterus towards or through the introitus
* 1st degree: descent of cervix within vagina but not through introitus
* 2nd degree: descent of cervix but not the whole uterus through introitus
* 3rd degree: descent of cervix and the whole uterus thorugh introitus usually bringing with cystocele, rectocele and enterocele
Define uterine procidentia
Herniation of all 3 compartments through the vaginal introitus
What are the components comprising of pelvic support?
What are the 3 levels of anatomy of pelvic floor?
What are the RF for pelvic organ prolapse?
What is the ddx for pelvic organ prolapse?
- Cervical polyp
- Bartholins gland cysts
- Skenes duct cysts
- Vaginal cysts
What is the clinical manifestation of POP?
What PE done for POP?
Sims retractor (single blade speculum) or bivalve speculum
Visual inspection
Speculum and bimanual examination
Apical prolapse: bivalve speculum is inserted into vagina and then slowly withdrawn and any descent of apex is noted
Anterior vaginal wall: sims retractor or posterior blade of bivalve speculum is inserted into vagina with gentle pressure on posterior vaginal wall to isolate visualization of anterior vaginal wall.
Posterior vaginal wall: sims retractor or posterior balde of bivalve speculum is inserted into vagina with gentle pressure on anterior vaginal wall to isolate visualization of posterior vaginal wall.
Rectovaginal examination: for dx of enterocele. Assess integrity of perineal body.
Neuromuscular examination
S2-4 nerve roots: sensory of lumbosacral dermatomes for light touch and pin prick sensation
Pelvic floor muscle testing: inspection for presence of scarring and whether pelvic floor contraction pulls perineum inwards
What Ix to do in pelvic organ prolapse?
- RFT
- Urinalysis (UTI)
- Urine smear and culture (UTI)
- Bladder diary
- Urodynamic test (gold standard but not indicated for everyone): cystometry (for urinary incontinence), post void residual (PVR) measurement (for urinary retention)
What is the conservative treatment for POP?
Indications?
Complications?
Ring/cube pessary
Indications
* Patient physically unfit for surgery
* Patients refusal for surgery
* Temporary relief while awaiting surgery
* Pregnancy or want to preserve uterus for fertility
Complications
* Vaginal ulceration leading to PV bleeding
* Foul smelling discharge
* Urinary retention
* Slippage of vaginal pessary
Pelvic floor muscel training
What is surgical treatment for cystocele?
Complications?
Anterior colporrhaphy = pelvic floor repair
Plication of pubocervical fascia so that the descended bladder (cystocele) is elevated with the support of fascia
Often performed together with vaginal hysterectomy or with the repair of perineum
Complications: bladder perforation
What is surgical treatment for rectocele?
Complications?
- Posterior colporrhaphy (pelvic floor repair)
- Plication of part of levator ani muscles between posterior vaginal wall and anterior vaginal wall so that the herniated rectum (rectocele) is reduced by reinforced muscle
- Often performed together with vaginal hysteretomy or with repair of perineum (perinorrhaphy) for deficient perineal body
Complications
* Rectal perforation
* Dyspareunia secondary to tight vaginal opening afte repair
What is surgical treatment for enterocele?
- McCall culdoplasty
What is surgical treatment for uterine prolapse?
How is the procedure done?
Complications?
Vaginal hysterectomy +/-pelvic floor repair
* Uterus removed vaginally +/- removal of ovaries and fallopian tubes but not in case difficulty encountered. If uterus does not descend after anesthesia then will proceed to pelvic floor repair only.
* Pelvic floor supporting tissue or ligament strengthened with sutures before closure of vaginal incision.
* Cystoscopy performed to look for urinary tract injury
Frequent complications
* Vaginal bleeding
* UTI/urinary frequency
* Wound infection
* Postop pain with difficulty or dyspareunia
Serious complications
* New or continuing bladder dysfunction including difficulty in voiding which may results in long term catheterization or intermittent self catheterization
* Develop or unmask stress incontinence
* Injury to adjacent organs: bladder, ureters, bowel
* Pelvic abscess
* DVT or PE
What are the indications for sacrocolpopexy?
What does the procedure involve?
Indications: vault prolapse with bothersome symptoms or those who failed non surgical treatment
Abd procedure which mesh attaches the vault to sacrum. Top and back of vagina is attached to a ligament on the lower part of the sacral bone using a piece of synthetic mesh or tape. Mesh is covered by a layer of tissue called peritoneum that lines the abd cavity.
Different from sacrospinous fixation (which fixes the vaginal vault to sacrospinous ligament, not the sacral bone in this case)
What are the indications for sacrospinous fixation?
What does the procedure involve?
What are its complications?
Indication
* Vault prolapse with bothersome symptoms or those who failed non-surgical treatment
Vaginal procedure in which the vaginal vault is sutured to one or more sacrospinous ligament. Less effective than sacrocolpopexy. Less invasive and more easily performed.
Serious complications
* Dyspareunia
* Development of cystocele
* Development of overactive bladder
* Development of stress urinary incontinence due to change in anatomy
* Recurrence of vault prolapse (18% very common)
What are the indications for colpocleisis?
What does the procedure involve?
What are its complications?
Indication: genital prolapse of vault prolapse with bothersome dragging discomfort, AE on bowel or urinary function or failed non surgical treatment
Vaginal incision: vaginal epithelium removed from anterior and posterior vaginal walls. Vagina obliterated by sutures. Perineorrhaphy. Cystoscopy performed to look for urinary tract injury.
Complications
Common: fever, UTI, wound infection, wound haematoma, post op pain
Serious : new or continuing bladder dysfunction
Develop or unmask stress urinary incontinence
Post op cardiac, thromboembolic and pulmonary events
Pelvic abscess
Bleeding requiring blood transfusion
Type sof urinary incontinence
- Urge incontinence: involuntary leakage of urine accompanied by urgency. Inability to withhold passage of urien with a sudden strong desire to micturate due to hyperexcitability of bladder detrusor muscles
- Stress incontinence: involuntary leakage of urine with exertion, sneezing or coughing
- Overflow incontinene: involutnary leakage of urine when intravesical pressure exceeds maximum urethral pressure deu to bladder distension and in the absence of detrusor activity. Secondary to bladder outflow obstruction
- True incontinence: defect in anatomical integrity –> vesicovaginal fistula
- Functional incontinence: involuntary leakage of urine due to non physiological causes: inability of getting into toilet in a timely fashion.
What nerves controlling bladder?
Sympathetic nervous system: hypogastric nerve (T10-L2)
Parasympathetic nervous system: pelvic splanchnic nerves (S2-4)
Detrusor muscles of bladder
Internal sphincter muscle: involuntary smooth muscle
External sphincter muscle: voluntary striated muscle
What is the efferent innervation of the bladder?
Whata are the different phases of micturition?
Classification of different types of urinary incontinence and causes?
Hx for urinary incontinence?
PE for urinary incontinence?
Pelvic exam: pelvic mass, POP, atrophic vaginitis
DRE: prostate size (male not in O&G) and consistency. Presence of rectal mass or faecal impaction
Bladder stress test
What Ix done for urinary incontinence?
- RFT
- Urinanalysis (rule out UTI)
- Urine culture (rule out UTI)
- Bladder diary (frequency volume chart)
- Urodynamic testing is gold stanard (includes cystometry, uroflowmetry)
- Urethral function testing (last line for patients with unexplained incontinence)
Non pharmacological treatment for urinary incontinence?
- Lifestyle modification: decrease fluid intake, reduction in cafeeine in women with overactive bladder. Advise weight reduction if BMI >30
- Bladder training: for >6 weeks as 1st line treatment for women with urge or mixed incontinence.
- Pelvic floor muscle training: >3 months duration as 1st line treatment to women with stress or mixed incontinence. Training protocal: contract muscle as hard as possible than rest the muscel for 5s. 3s squeeze, 4 squeezes per set, 5 sets per day and should be spread out
Medical treatment for urinary incontinence?
Antimuscarinic drugs: oxybutynin/solifenacin –> for overactive bladder or urge incontinence
B3 adrenergic agonists (mirabegron)
Duloxetine: for stress incontinence
Desmopressin
Surgical treatment options for urge incontinence?
- Percutaneous sacral nerve stimulation
- Injection of botulinum toxin A via cystoscopy
- Augmentation cystoplasty
- Urinary diversion
Surgical treatment options for stress incontinence?
- Tension free vaginal tape
- Burch colposuspension
- Synthetic mid urethral tape
- Autologous rectus fascial sling
Indications for tension free vaginal tape?
Complications?
Indications: urodynamic stress incontinence (most commonly performed surgical procefure for USI)
Small vaginal incision near urethra. Passage of synthetic tape on either side of the urethra through vagina incision. Tape is passed into a tunnel created around each side of bladder neck and out at abd incisions or thigh folds.
Frequent complications
* UTI, wound complications including hernia and infection
Serious complications
* Development of overactive bladder
* Voiding difficulty which may require intermittent self catheterization and may be prolonged and lasted more than 6 months
* Bladder injury may require repeair or urinary diversion
Indications for burch colposuspension?
Complications?
Indications: urodynamic stress incontinence
Abd incision. Space behind the pubic bone entered (abd cavity need not be entered). Bladder neck region identified. Stitches placed into the tissue on either side of bladder neck and attached to a ligament on each side of the pelvis. Stitches are tied and the bladder neck is lifted up.
Serious complications
* Development of urge urinary incontinenve
* Development of vaginal wall prolapse
* Voiding difficulty and urinary retention which may necessitate bladder drainage with a catheter or even self catheterization
* Failure to improve incontinence symptoms
* DVT or PE
