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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

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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

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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

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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.

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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

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7
Q

What are the biggest risk factors for mesh exposure?

A

Concomitant hysterectomy and smoking.

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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

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9
Q

Fesoterodine: type of agent

A

Non-specific muscarinic receptor antagonist
(Anticholinergic/antimuscarinic)

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10
Q

Fesoterodine dosing

A

4 or 8 mg

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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

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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

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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

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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

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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

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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

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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

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18
Q

Continuation rates of anticholinergics at 1 year

A

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

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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

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20
Q

Benefit of fesoterodine 4 mg over 8 mg (1)

A

34-58% less likely to have dry mouth

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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

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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)

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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%

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24
Q

Mirabegron: type of agent

A

Selective beta3 adrenoreceptor agonist

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25
Q

Mirabegron starting dose (2 options)

Max dose?

A

25 or 50 mg

May escalate to 300 mg max if < 65 years, 200 max if 65+ years

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26
Q

What percent of adrenoreceptors in the bladder are beta3?

A

95%

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27
Q

What detrusor muscle fibres give a sensation of bladder fullness?

What fibres in urothelium and lamina propria lead to sensation of bladder fullness?

A

Aδ fibres in detrusor

C fibres in urothelium and lamina propria

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28
Q

If a full bladder and voiding is socially acceptable, what sequence of actions occurs?

A

Brain activates nerves such that efferent muscarinic parasympathetic fibres release acetylcholine, leading to detrusor contraction

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29
Q

If a full bladder and voiding is NOT socially acceptable, what sequence of actions occurs?

A

Brain activates nerves such that efferent adrenergic sympathetic fibres release epinephrine, leading to detrusor relaxation

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30
Q

What are the mechanisms of action of mirabegron to prevent urge incontinence? (2)

A
  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

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31
Q

Mirabegron pharmacology

A

Rapidly absorbed and metabolized in liver
Excreted mainly unchanged in urine and feces
May interact with drugs metabolized by CYP enzymes

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32
Q

What are 2 reasons you may need dose adjustments for mirabegron? (2)

A
  1. Severe renal impairment
  2. Moderate to severe hepatic impairment

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33
Q

What medication may need dose adjustment if a patient is started on mirabegron?

A

Digoxin
Will also need close monitoring of digoxin levels

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34
Q

Does mirabegron have side effects?

A

Low incidence of headache/dizziness
Not well-studied for dementia/other neurological diseases
No dry mouth or constipation
No urinary retention

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35
Q

Is mirabegron safe in glaucoma?

A

Possibly. There is no increase in intraocular pressures in healthy volunteers

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36
Q

CVS effects of mirabegron? (3)

A
  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)

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37
Q

Risk factors to ideally control before starting mirabegron (5)

If risk factors are not controlled for, what should be periodically monitored? (2)

A
  1. Hypertension
  2. Arrhythmia
  3. Angina
  4. Heart failure
  5. Age > 80 years
  6. BP
  7. HR

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38
Q

What is the FORTA classification for mirabegron?

A

C - careful

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39
Q

Most common reason for mirabegron discontinuation in OAB treatment?

A

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

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40
Q

Is mirabegron a 1st line treatment for OAB?

A

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.”

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41
Q

Can you combine anticholinergics with mirabegron?

A

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)

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42
Q

Benefit of mesh vs. non-mesh SUI procedures (4)

A
  1. Shorter OR time
  2. Faster return to normal daily activities
  3. Better or similar success
  4. Lower complication rate

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43
Q

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?

A

Retropubic approach has more:

  • bladder perforation
  • voiding dysfunction

Transobturator approach has more:
- groin pain

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44
Q

What is the efficacy of mesh procedures for SUI over 5 years?

A

80%

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45
Q

Name 1 non-surgical and 4 surgical managements of SUI

A

Non-surgical:
- incontinence devices (pessary)

Surgical:

  • retropubic mesh procedure
  • transobturator mesh procedure
  • autologous pubovaginal sling (non-mesh)
  • Burch colposuspension (non-mesh)

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46
Q

What percent of Canadian women does SUI affect?

A

25%

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47
Q

What is the most reliable assessment on physical exam that confirms the diagnosis of stress urinary incontinence?

A

Cough stress test

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48
Q

What % of women with pelvic organ prolapse have some degree of hydronephrosis on renal ultrasound?

A

17%

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49
Q

Name (4) indications for urodynamic testing.

A

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

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50
Q

Name (6) indications for cystoscopy.

A

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

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RC ObGYN 2021 (11 decks)

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