Women's Health : Urogynaecology Flashcards
What is pelvic organ prolapse?
Herniation of one more pelvic organ into the vagina.
What provides Level 1 support in the pelvis?
Uterosacral ligaments - extend posteriorly from cervix / upper vagina to the sacral spine.
What structure is involved in Level 2 support?
Arcus tendineus fasciae pelvis (ATFP) - runs from ischial spines to pubic tubercle, attaching to sheets of suspensory ‘slings’ of fascial tissue e.g. pubovesicocervical fascia.
What structures are involved in Level 3 support?
Perineal body - fibromuscular mass, point of attachment for pelvic muscles. - Pubourethral ligaments. - Pelvic floor - (levator ani and coccygeus muscles).
What is the role of the perineal body?
Attachment for pelvic muscles
What are the supporting structures of the pelvic floor?
Pubourethral ligaments, pelvic floor muscles (levator ani and coccygeus muscles), uterosacral ligament, and ATFP
What causes uterine prolapse?
Uterosacral ligament weakness
What causes cystocele/rectocele?
ATFP weakness
What causes urethrocele?
Pubourethral ligament weakness -
What is the primary cause of pelvic organ prolapse?
Loss of support due to factors like pregnancy, vaginal delivery, and surgery
What is the primary risk factor for pelvic organ prolapse?
Vaginal delivery
What are the contributing risk factors for pelvic organ prolapse?
Increasing age and high BMI
Why does vaginal delivery lead to pelvic organ prolapse?
(risk increased with increasing parity) - damage to nerves, muscles and fascia
Why does increasing age lead to pelvic organ prolapse?
- reduced elasticity of connective tissue
Why does high BMI lead to pelvic organ prolapse?
- raised intra-abdominal pressure
What are the types of pelvic organ prolapse?
Uterine, enterocele, cystocele, rectocele, and urethrocele
What is uterine prolapse?
descent of cervix +/- uterus into the vagina.
What is urethrocele?
- prolapse of the urethra into anterior vaginal wall
What is cystocele?
prolapse of bladder into anterior vaginal wall.
What is rectocele?
prolapse of rectum into posterior vaginal wall.
What is enterocele?
- prolapse of the small bowel through the Pouch of Douglas into the posterior vault of the vagina.
Uterine prolapse symptoms?
vaginal pressure, dyspareunia, feeling of something descending into the vagina.
Urethrocele symptom?
Stress incontinence
Cystocele symptoms?
Recurrent UTI, difficulty passing urine
Rectocele symptom?
Difficulty defecating
Enterocele symptom?
Dragging sensation
Sign of uterine prolapse?
Descended cervix/uterus
Sign of urethrocele on exam?
Anterior protrusion into vaginal vault
Sign of cystocele on exam?
Anterior protrusion into vaginal vault
Sign of rectocele on exam?
Posterior protrusion into vaginal vault
Sign of enterocele on exam?
Posterior protrusion into vaginal vault
How is the condition typically diagnosed?
Clinically based on symptoms
What is a conservative management option for pelvic issues?
○ Pelvic floor exercises. ○ Avoidance of triggers e.g. heavy lifting, straining in constipation. ○ Weight loss, if overweight. ○ Topical oestrogen (counteracts urogenital atrophy - see Menopause). ○ Pessaries
What is a surgical option for uterine management?
- options include hysterectomy, sacro-hysteropexy (mesh), Manchester repair
What is a surgical option for vaginal vault managment?
options include sacrospinous fixation, sacro-colpopexy (mesh)
What is a topical treatment for urogenital atrophy?
Topical oestrogen
What is urinary incontinence?
Involuntary passage of urine
What is stress incontinence?
- urinary loss during a period of raised intra-abdominal pressure e.g. coughing, sneezing.
What characterizes urge incontinence?
urinary loss characterised by increased urge to pass urine - associated with detrusor muscle overactivity.
What is mixed incontinence?
Combination of stress and urge incontinence
The physiology of Continence is split into 2 phases, what are they called?
Storage and Voiding phases
What transmits impulses to the pontine continence centre?
Cerebral cortex
Which spinal cord segments are involved in the pontine continence centre signals?
T10-L2
What does the sympathetic hypogastric nerve stimulate?
Detrusor relaxation, Internal urethral sphincter contraction
Somatic innervation of the ______ also contributes to continence during bladder filling
external urethral sphincter
_____from the distended bladder ascend via the spinal cord to the pontine micturition centre and the cerebral cortex (conscious urge to pass urine)
Afferent signals
______________ signals to the detrusor cause it to contract, transmitted via S2-4 pelvic splanchnic nerve.
Efferent parasympathetic
Inhibition of _________ (due to pontine micturition centre activity) reduces sympathetic storage-promoting activity.
Onuf’s nucleus
Conscious relaxation of external urethral sphincter via __________ fibres allows passage of urine.
somatic pudendal nerve
What is the role of the detrusor muscle during voiding?
Contracts via parasympathetic signals
Which nerves transmit parasympathetic signals to the detrusor?
S2-4 pelvic splanchnic nerve
What effect does the pontine micturition centre have on Onuf’s nucleus?
Inhibits sympathetic activity
How is the external urethral sphincter relaxed during voiding?
Somatic pudendal nerve fibers
Role of Sympathetic Nerves (T10-L2)
Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing
Role of Parasympathetic Nerves (S2-4)
Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening
Role of Somatic Afferent Nerves (S2-4)
Somatic afferent - S2-4 pudendal - sensation of bladder fullness
Role of Somatic Efferent Nerves (S2-3)
Somatic efferent - S2-3 pudendal - closes / opens EUS.
Continence Mechanism for Intra-abdominal Pressure
- Reflexive contraction of the pelvic floor muscles elevates the IUS. 2. Augmentation of pelvic floor muscle closure by suspensory ligaments. 3. Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure.
What role do suspensory ligaments play?
Augment pelvic floor muscle closure
What assists with urethral closure?
Urethrovaginal sphincter contraction
What increases intra-vesical pressure in stress incontinence?
Raised intra-abdominal pressure
What leads to leakage in stress incontinence?
○ Raised intra-abdominal pressure increases intra-vesical pressure. ○ IVP exceeds resistance of urethral sphincters leading to leakage. ○ This typically occurs due to downward movement of the internal sp
What leads to urge incontinence?
Mechanism not fully understood - likely a combination of myopathy and neuropathy.
What causes urethral hypermobility?
Pelvic floor weakness
Urge incontinence mechanism?
Myopathy, neuropathy
Risk factors for incontinence
- Increasing age 2. High BMI 3. High parity 4. Pelvic organ prolapse
What is stress incontinence?
- involuntary passage of urine during activities that raise intra-abdominal pressure (sneezing, coughing etc.)
What is urge incontinence?
- involuntary passage of urine with associated urge to pass urine, increased urinary frequency.
What is the first line investigation for urinary incontinence?
urinalysis to rule out UTI, plus: ○ Bladder diary ○ Symptom questionnaire
What is included in the second line investigations?
urinary stress testing, e.g. ○ Cough stress test ○ Empty supine stress test
What is the first line management for stress incontinence?
pelvic floor exercises (8 contractions x3 per day) + lifestyle measures e.g. reducing caffeine, weight loss, moderate fluid intake
What is the second line management for stress incontinence?
(for some patients) - pseudoephedrine, topical oestrogen
What is the third line management for stress incontinence?
surgery such as retropubic colposuspension.
First Line (urge incontinence)
bladder training
Second Line (urge incontinence)
anticholinergic e.g. oxybutynin, solifenacin
Third Line (urge incontinence)
mirabegron (beta-3 agonist)
Plus (atropic vaginitis)
topical oestrogen if atrophic vaginitis present
