Vulva & Genitourinary Flashcards
Stress incontinence
Triggered by increased pressure on sphincter/ bladder
Urge incontinence
Overwhelming sensation to urinate due to overactivity of the detrusor muscles
Causes of overflow incontinence
Medication
- Anticholinergics
Anatomical obstruction
- Fibroids
- Pelvic tumours
Neurological
- MS
- Spinal cord injury
- Diabetic neuropathy
Risk factors for incontinence in women
Pregnancy related
- Previous vaginal delivery
- Gravida
Surgery
- Pelvic floor surgery
Demographic
- Increased age
- High BMI
- Post-menopausal
Neurological
- MS, spinal cord lesion
- Cognitive impairment.
Oxford grading system for pelvic floor muscle
Used to grade the strength of contraction of pelvic floor muscles during bimanual exam
<2 = weak, very weak or no contraction
3= moderate
4,5= good, strong
What things should be assessed for in incontinence?
- Pelvic organ prolapse
- Atrophic vaginitis
- Pelvic masses
- Urethral diverticulum
Initial investigations in incontinence
Bladder diary
- Minimum 3 days
Urine dipstick
- Rule out infection, kidney damage
- Mid-stream MCS if positive for nitrites and leucocytes
Urodynamic tests for urinary incontinence
Investigation that compares the pressure in rectum compared to bladder
2-week wait indications in incontinence
45+ and
- Unexplained frank haematuria without UTI
- Frank haematuria after UTI treatment
60+ with Unexplained non-visible haematuria AND
- Dysuria or
- Raised WCC on blood test
Lifestyle management for stress incontinence
- Avoid caffeine
- Sensible fluid intake/ overfilling bladder
- Weight loss if BMI > 30
- Smoking cessation
Non-pharmacological treatments for stress incontinence
At least 3 months of supervised pelvic floor muscle training
- At least 8 pelvic floor contractions 3x daily
Secondary care treatment of stress urinary incontinence
Surgery
- Tension-free vaginal tape
- Colposuspension
- Autologous rectus fascial sling
- Retropubic mid-urethral mesh sling
- intramural urethral bulking agents.
Medication (if surgery not suitable or preferred)
- Duloxetine
Initial management of overactive bladder
Bladder training
- Via continence physiotherapist/ continence nurse
- At least 6 weeks
- 8 PFM contractions at least 3x day
Second line treatment for urge incontinence + side effects
Antimuscurinic medications
- Oxybutynin immediate release
- Tolterodine immediate release
- Darifenancin
Side effects
- Dry mouth
- Constipation
- Drowsiness
3rd line management for urge incontinence (if bladder training and anti-muscarinics fail)
Mirabegron
- Beta-3 agonist
Contraindications of mirabegron
Uncontrolled hypertension
Medication to manage nocturia
Desmopressin
Contraindications of desmopression
> 65
Uncontrolled hypertension
CVD
Last line management of urge incontinence
Botulinum toxin type A injections
Surgery
Cystometry and Uroflowmetry
Urodynamic test that measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure
Urodynamic test that measures pressure required to cause leakage of urine
- Assess stress incontinence
Colposuspension
Surgery that involves stitches connecting the anterior vaginal wall and the pubic symphysis.
The stitches go around the urethra, and pulls the vaginal wall forwards and adding support to the urethra
Vulva carcinomas typically spread lymphatically to _______
Inguinal and femoral nodes
Most common type of vulva cancer is _______
Squamous cell carcinoma
