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RCPSC > urogynae > Flashcards

urogynae Flashcards

1
Q

vaginal suture suspension is inferior to aSCP for which outcomes?

A
  1. overall objective failure
  2. objective apical failure
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2
Q

risk of mesh exposure with aSCP

A

2.7-3.4%

persisting up to 7 years postop

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3
Q

open aSCP vs. MIS SCP inferior for which outcomes?

A
  1. overall objective failure
  2. objective posterior failure
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4
Q

uterosacral ligament suspension vs. SSF has a higher risk of?

A

intraoperative ureteric injury

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5
Q

hysterectomy and suspension vs. hysteropexy were inferior for ?

A

objective posterior failure

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6
Q

hysterectomy + SCP vs. sacrohysteropexy showed a higher risk of?

A

mesh exposure

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7
Q

uterosacral ligament suspension fixation vs. SSF showed a lower risk of

A

short-term/transient buttock pain

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8
Q

POP is symptomatic in what proportion of women

A

3-6%

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9
Q

lifetime incidence of surgery for POP

A

12.6-19%

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10
Q

rate of reoperation for POP

A

30%

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11
Q

specificity of urodynamic testing

A

93%

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12
Q

women can be successfully fitted with a pessary up to ___%

A

75% of the time

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13
Q

pessary for pop relieves _____ in 70-90% of women

A

symptoms of bulging

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14
Q

pessaries relieve symptoms of pressure in ___%

A

29-49% of women

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15
Q

most common pessaries for POP

A
  1. ring pessary
  2. gellhorn
  3. cube
  4. donut
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16
Q

predictors for unsuccessful pessary fitting

A

A. short vagina <6cm
B. wide Introits >4 fingers
C. GH:TVL ratio >0.8
D. patient discomfort
E. age <65
F. hx of smoking
G. lower initial prolapse stage
H. previous vaginal surgery

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17
Q

what proportion of women required a second fitting with a gellhorn

A

about one third (29-35%)

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18
Q

factors that predict discontinuation of pessary use:

A
  1. posterior wall prolapse
  2. age <65
  3. UI
  4. discomfort
  5. expulsion
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19
Q

pessary for urinary incontinence - rate of use drops by…

A

drops to 55% by 6 months
by 1 year, overall continuation may be as low as 16%.

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20
Q

incidence of uterine prolapse in pregnancy

A

1/13 000 to 15 000 pregnancies

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21
Q

after placement of a ring pessary, what manoeuvre?

A

rotation quarter-turn in either direction to prevent foldable edge from being placed in front of the introitus

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22
Q

after placement of a ring pessary, patient should:

A

walk around in the clinic and perform activities such as squatting and the valsalva;
ensure they can void

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23
Q

after a successful pessary fitting, what follow-up?

A

2-4 weeks to see whether satisfied

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24
Q

how often to perform self-care of pessary

A

weekly to monthly according to preference

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25
Q

if unable to perform self-care of pessary, follow-up required?

A

3 monthly intervals

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26
Q

cube pessary requires removal and cleaning every

A

3 month

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27
Q

complication rate for pessary use overall

A

?11%
possibly as high as 73%

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28
Q

reported rates of devascularization with pessary use

A

2-9%

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29
Q

what can help with recalcitrant ulcerations (pessary use)

A

douching with 10% sucralfate suspension twice daily

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30
Q

rate of pessary expulsion

A

16.3%

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31
Q

pessary use - major complication rate

A

3% at 9 years

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32
Q

what PVR volume requires further investigations?

A

> 150ml (persistently)

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33
Q

indications for urodynamics

A
  • complicated UI symptoms
  • UI refractory to treatment
  • prior incontinence procedures
  • stage 3-4 prolapse
  • conflicting Hx and physical
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34
Q

indications for cystoscopy (in UI)

A
  • UI refractory to treatment
  • continuous leakage
  • persistent post-void dribbling
  • hematuria
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35
Q

comfortably full bladder at volume?

A

200-300ml

36
Q

urethral hyper mobility - angle

A

> =30deg from the supine horizontal plane

37
Q

hydronephrosis in women with prolapse

incidence

A

17% had some degree of it

38
Q

fesoterodine mechanism

A

non-specific competitive muscarinic receptor antagonist

39
Q

fesoterodine contraindications

A
  • gastric or urinary retention
  • uncontrolled narrow angle glaucoma
  • severe myasthenia gravis
  • severe hepatic impairment
40
Q

fesoterodine max dose of 4mg for:

A
  • pts with severe renal impairment (eGFR<30)
  • concomitant use of CYP inhibitor medications
41
Q

most common side effect of fesoterodine (8mg)

A

dry mouth = 29%

(second most common = constipation)

42
Q

rx recommendation for nocturnal bladder symptoms

A

fesoterodine

43
Q

rx recommendation for pts with pre-existing cardiac concerns for OAB

A

1) fesoterodine,
2) tolterodine
3) darifenacin,

44
Q

rx recommendation for pts on concomitant cholinesterase inhibitors for OAB

A

trospium

45
Q

rx recommendation for pts with concomitant use of CYP450 inhibitors for OAB

A

trospium

46
Q

examples of CYP inhibitors

A

antifungals, antiretrovirals, macrolides

47
Q

which OAB medication has renal metabolism

A

trospium

48
Q

solifenacin: receptor selectivity

A

M1 M3

49
Q

darifenancin: receptor selectivity

A

M3

50
Q

mirabegron mechanisms

A

selective B3 adrenoceptor agonist

decreases spontaneous bladder contraction and sensation of urgency

51
Q

mirabegron caution for patients with

A
  • poorly controlled CVD risk factors
  • patients >80
52
Q

mirabegron is recommended for OAB when

A
  • pts intolerable side effects
  • or suboptimal response

on anticholinergic Rx

53
Q

prevalence of OAB

A

11-17%

54
Q

what proportion of women with OAB will report a negative effect on daily living

A

67%

55
Q

comorbidities associated with OAB

A
  • depression
  • falls & fractures
  • admissions
56
Q

normal voiding occurs via…

A

parasympathetic activation of M2/M3 receptors

57
Q

which receptors inhibit sympathetically mediated bladder relaxation

A

M2

58
Q

NNT for anticholinergics/OAB

A

7

59
Q

oxybutinin is associated with significant anticholinergic effects in up to

A

80% of patients

60
Q

discontinuation rate of oxybutinin

A

33%

61
Q

lower urinary tract derives from

A

cloaca

62
Q

options for refractory OAB symptoms

A
  1. botox
  2. central neurostim
  3. peripheral neurostim
63
Q

what proportion of women with botox for OAB needed ISC

A

43%

… dose dependant

64
Q

complications of sacral nerve stimulation

A
  • lead migration
  • pain
  • infection

… 33% re-operation rate

65
Q

tibial nerve stimulation for OAB - treatment benefit sustained at

A

12 months

66
Q

only OAB drug that has successful dose escalation

A

fesoterodine
but increased SEs

nb - other drugs, has subjective improvement only with dose escalation

67
Q

OAB drug with superior cost-effectiveness

A

oxybutinin
but more SEs

(less with transdermal)

68
Q

OAB drugs available in transdermal

A

oxybutinin only

69
Q

OAB drugs available in extended release

A

1) oxybutinin
2) tolterodine
3) trospium

70
Q

OAB pts should be offered a choice between

A

1) bladder training
2) functional electric stimulation
3) anticholinergic rx

no difference in cure rates

71
Q

vaginal suture suspension includes which procedures

A
  • uterosacral suspension
  • SSF
  • McCall culdoplasty
  • ileococcygeal suspension
72
Q

what is sufficient for dx of uncomplicated SUI

A
  • normal PVR
  • clear Hx
  • absence of POP
  • no prior pelvic surgery
  • no concurrent urge or voiding symptoms
73
Q

vaginal suture suspension vs. aSCP: recommendation

A

counsel regarding higher objective failure rate but less risk of mesh

74
Q

open SCP vs MIS SCP - favour which?

A

MIS

75
Q

uterosacral ligament suspension vs. SSF - recommendation?

A

can offer both

76
Q

recurrent UI after surgery - urodynamics not required if?

A
  • one or less surgery for UI
  • Sx of SUI only
  • hypermobile urethra
  • PVR <100
  • normal UA
77
Q

urodynamics: internal sphincter deficiency dx if max closing pressure?

A

<20cm H20

78
Q

urodynamics: internal sphincter deficiency dx if leak point pressure

A

<60cm H20

79
Q

effects of repeat surgery on urethral fxn

A
  • scarring
  • poorly vascularized, rigid, lead pipe
  • poor coaptation
  • smooth, rigid tube
  • immobile and open
80
Q

recurrent UI - pts with a hypermobile urethra but w/o evidence of intrinsic sphincter deficiency, may be managed with -

A
  • retropubic urethropexy (burch)
  • sling procedure
81
Q

recurrent UI + evidence of intrinsice sphincter deficiency may be managed with

A
  • sling procedure

retropubic TVT should be considered rather than TOT (better success rate 74-82%)

82
Q

recurrent UI - decreased urethral mobility may be managed with

A
  • periurethral bulking injections
  • retropubic sling procedure
  • artificial sphincter
  • urinary diversion
  • chronic catheterization
83
Q

recurrent UI - assessment for what causes?

A
  • compromise to urethral sphincter mechanism
  • detrusor overactivity (OAB)
  • voiding dysfxn
  • urogenital fistula
  • persistent or de novo pelvic prolapse
84
Q

urogenital fistula - how to dx vesicovaginal

A

methylene blue into bladder

85
Q

how to dx urethral or bladder fistula

A

cystourethroscopy

86
Q

how to dx ureterovaginal fistula

A

injxn of IV indigocarmine

87
Q

how to dx upper urinary tract damage

A

IV pyelography
or
CT w/contrast

RCPSC (17 decks)

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