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RC ObGYN 2021 > Urogynecology > Flashcards

Urogynecology Flashcards

1
Q

What percentage of women who undergo mid-urethral sling will need re-operation?

A

3% of women who get a mid-urethral sling will ne re-operation for mesh-related complications

SOGC 387

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2
Q

For patients who get mid-urethral slings, what type of mesh is placed?

A

Placement of a permanent strip of Type 1 monofilament polypropylene mesh at the level of the urethra

SOGC 387

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3
Q

Name possible complications of mid-urethral slings. (10)

A 
Complications
	• Voiding dysfunction
	• Mesh tape erosion/exposure
	• Acute pain
	• Chronic pelvic pain
	• Infection
	• Dyspareunia
	• Bleeding
	• Neuromuscular injury
	• Organ injury
	• Recurrent SUI

SOGC 387

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4
Q

Which type of mesh is shown to have less risk of complications?

A

Polypropylene Type 1 Monofilament, macroporous synthetic mesh

SOGC 351

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5
Q

True or False.
Polypropylene mesh have better subjective and objective success rates for posterior vaginal wall compared to native tissue repair.

A

False.
It only has better success rates for ANTERIOR vaginal wall.

There is a 60% risk reduction of recurrent objective prolapse after transvaginal mesh use in any compartment.

SOGC 351

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6
Q

What is the % of risk of vaginal mesh exposure? What are some symptoms experienced by patients with vaginal mesh exposure?

A

Risk is 12%.
If in anterior compartment, only 10%. If multicompartment, 17%.

Symptoms include:

  • vaginal discharge
  • bleeding
  • pain
  • dyspareunia
  • Partner feeling discomfort during intercourse

SOGC 351

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7
Q

What are the biggest risk factors for mesh exposure?

A

Concomitant hysterectomy and smoking.

SOGC 351

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8
Q

Definition overactive bladder (OAB)

A

Increased urgency, frequency, or nocturia +/- urgency incontinence in the absence of UTI or other pathology

SOGC 353

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9
Q

Fesoterodine: type of agent

A

Non-specific muscarinic receptor antagonist
(Anticholinergic/antimuscarinic)

SOGC 353

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10
Q

Fesoterodine dosing

A

4 or 8 mg

SOGC 353

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11
Q

Fesoterodine pharmacology

A

It is rapidly & extensively hydrolyzed into 5-hydroxymethyl tolterodine by non-specific esterases in the gut, then metabolized by CYP-2D6 and CYP-2A4 in the liver

SOGC 353

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12
Q

Contraindications to fesoterodine (4)

2 additional contraindications to the higher dose (8mg)

A
  1. Gastric or urinary retention
  2. Uncontrolled narrow angle glaucoma
  3. Severe myasthenia gravis
  4. Severe hepatic impairment

8mg contraindications:

  1. Severe renal impairment (CrCl < 30 mL/min)
  2. Patient also on a CYP inhibitor medication

SOGC 353

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13
Q

In which populations has fesoterodine been found to be safe/beneficial compared to other anticholinergics? (4)

A

Elderly and frail elderly
Pre-existing cardiac conditions
Cognitive dysfunction
Patients with nocturnal OAB symptoms to improve sleep quality

SOGC 353

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14
Q

If fesoterodine 4 mg doesn’t work, is it better to change to another agent or try escalating to 8 mg?

A 
Dose escalation (8 mg)
It improves drug efficacy
Both doses are safe &amp; effective for OAB symptoms, even after 24 months

SOGC 353

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15
Q

What is the FORTA classification? What does each class stand for?

A

Fit fOR The Aged

It describes if a drug is safe for use in the elderly

A - absolutely
B - beneficial
C - careful
D - don’t use

SOGC 353

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16
Q

What is the only anticholinergic agent with FORTA classification B? What classification are all the others?

A

Fesoterodine

All other anticholinergics are class C

SOGC 353

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17
Q

Side effects of fesoterodine in the elderly

A 
Dry mouth (34%)
Constipation (9%)

Rarely urinary retention, CVS & CNS events

No change in cognition

This is why it’s a great medication for elderly patients

SOGC 353

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18
Q

Continuation rates of anticholinergics at 1 year

A

Fesoterodine - 35.8%
Solifenacin - 31.9%
Tolterodine - 30.8%

SOGC 353

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19
Q

Benefits of fesoterodine 8 mg over placebo (3)

A
  1. Decreased # of nocturnal mixture ruins
  2. Decreased # of nocturnal urgency episodes
  3. Improved subjective sleep quality

SOGC 353

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20
Q

Benefit of fesoterodine 4 mg over 8 mg (1)

A

34-58% less likely to have dry mouth

SOGC 353

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21
Q

If a patient is on tolterodine ER 4 mg and has suboptimal response, how might you improve their response?

A

Change to fesoterodine 8 mg

SOGC 353

22
Q

Comparing fesoterodine 8 mg vs. tolterodine ER 4 mg (3 benefits, 1 downside)

A
  1. Better condition-specific quality of life
  2. Better patient-reported cute (74% vs. 66%)
  3. Decreased # of micturitions, leakage episodes, and urgency in 24 hours
  4. Increased withdrawals due to adverse events & dry mouth (this effect is nullified by fesoterodine 4 mg, however)

SOGC 353

23
Q

Rates of dry mouth and constipation in fesoterodine vs. tolterodine vs. placebo

A

Dry mouth: F 29%, T 15%, P 6%
Constipation: F 5%, T 4%, P 2%

SOGC 353

24
Q

Mirabegron: type of agent

A

Selective beta3 adrenoreceptor agonist

SOGC 353

25
Mirabegron starting dose (2 options) | Max dose?
25 or 50 mg May escalate to 300 mg max if < 65 years, 200 max if 65+ years SOGC 353
26
What percent of adrenoreceptors in the bladder are beta3?
95% SOGC 353
27
What detrusor muscle fibres give a sensation of bladder fullness? What fibres in urothelium and lamina propria lead to sensation of bladder fullness?
Aδ fibres in detrusor C fibres in urothelium and lamina propria SOGC 353
28
If a full bladder and voiding is socially acceptable, what sequence of actions occurs?
Brain activates nerves such that efferent muscarinic parasympathetic fibres release acetylcholine, leading to detrusor contraction SOGC 353
29
If a full bladder and voiding is NOT socially acceptable, what sequence of actions occurs?
Brain activates nerves such that efferent adrenergic sympathetic fibres release epinephrine, leading to detrusor relaxation SOGC 353
30
What are the mechanisms of action of mirabegron to prevent urge incontinence? (2)
1. It improves urine storage by stimulating sympathetic detrusor (relaxation) and urothelium (contraction of urethra, therefore holding in urine) receptors 2. It decreased Aδ and C fibre afferent activity, decreasing spontaneous bladder contractions and sensation of urgency in response to bladder filling SOGC 353
31
Mirabegron pharmacology
Rapidly absorbed and metabolized in liver Excreted mainly unchanged in urine and feces May interact with drugs metabolized by CYP enzymes SOGC 353
32
What are 2 reasons you may need dose adjustments for mirabegron? (2)
1. Severe renal impairment 2. Moderate to severe hepatic impairment SOGC 353
33
What medication may need dose adjustment if a patient is started on mirabegron?
Digoxin Will also need close monitoring of digoxin levels SOGC 353
34
Does mirabegron have side effects?
Low incidence of headache/dizziness Not well-studied for dementia/other neurological diseases No dry mouth or constipation No urinary retention SOGC 353
35
Is mirabegron safe in glaucoma?
Possibly. There is no increase in intraocular pressures in healthy volunteers SOGC 353
36
CVS effects of mirabegron? (3)
1. At 200 mg, small statistically significant increase in HR, but no change in CVS adverse events 2. At 200 mg, prolonged QT interval, suggesting a pro-arrhythmic effect 3. 5 mmHg increase in systolic BP in healthy volunteers, but no difference in the OAB population (e.g. those with HTN, DM) SOGC 353
37
Risk factors to ideally control before starting mirabegron (5) If risk factors are not controlled for, what should be periodically monitored? (2)
1. Hypertension 2. Arrhythmia 3. Angina 4. Heart failure 5. Age > 80 years 1. BP 2. HR SOGC 353
38
What is the FORTA classification for mirabegron?
C - careful SOGC 353
39
Most common reason for mirabegron discontinuation in OAB treatment?
Lack of clinical efficacy Continuation rates are 12.2-39% at 12 months Patients are more likely to discontinue mirabegron if it was the first agent they’ve tried for their OAB compared to if they have previously tried an anticholinergic SOGC 353
40
Is mirabegron a 1st line treatment for OAB?
No. It is second line. “Further research is needed before mirabegron can be widely accepted as first-line OAB drug therapy; until then, mirabegron has a role in the treatment of patients who experience intolerable side effects from anticholinergic therapy or as an alternative when clinical response to anticholinergics is suboptimal.” SOGC 353
41
Can you combine anticholinergics with mirabegron?
There are theoretical synergistic advantages. However: “Combination therapy between anticholinergics and mirabegron has been minimally studied and cannot be strongly recommended at this time.” (It has only been studied in combination with solifenacin) SOGC 353
42
Benefit of mesh vs. non-mesh SUI procedures (4)
1. Shorter OR time 2. Faster return to normal daily activities 3. Better or similar success 4. Lower complication rate SOGC 387
43
Comparing mid-urethral sling procedures that use mesh for SUI, which complications (2) are more common in retropubic approach and which complication (1) is more common in transobturator approach?
Retropubic approach has more: - bladder perforation - voiding dysfunction Transobturator approach has more: - groin pain SOGC 387
44
What is the efficacy of mesh procedures for SUI over 5 years?
80% SOGC 387
45
Name 1 non-surgical and 4 surgical managements of SUI
Non-surgical: - incontinence devices (pessary) Surgical: - retropubic mesh procedure - transobturator mesh procedure - autologous pubovaginal sling (non-mesh) - Burch colposuspension (non-mesh) SOGC 387
46
What percent of Canadian women does SUI affect?
25% SOGC 387
47
What is the most reliable assessment on physical exam that confirms the diagnosis of stress urinary incontinence?
Cough stress test SOGC 397
48
What % of women with pelvic organ prolapse have some degree of hydronephrosis on renal ultrasound?
17% SOGC 397
49
Name (4) indications for urodynamic testing.
Current indications for urodynamic testing: - Presence of complicated stress urinary incontinence or mixed urinary incontinence - When objective findings do not correlated with subjective symptoms - Treatment failure - Surgical planning in select instances Other indications include: - Women with refractory or complicated urinary incontinence symptoms - Who have undergone prior incontinence procedures -Urinary incontinence in the setting of Stage 3-4 pelvic pelvic organ prolapse SOGC 397
50
Name (6) indications for cystoscopy.
Cystoscopy is indicated in women with refractory UUI in the absence of UTI - In women with continuous urinary leakage suspicious for genitourinary fistula - Iatrogenic genitourinary injuries - Post-void dribbling suggestive of presence of urethral diverticulum - Rapidly worsening UI symptoms - Hematuria - Risk factors for bladder malignancy SOGC 397

RC ObGYN 2021 (11 decks)

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