GYN- urogyn

Question 1

Stages of prolapse

Answer 1

0: no prolapse
1: most distal prolapse more than 1 cm above the hymen
2: most distal prolapse between 1 cm above and 1 cm below hymen
3: most distal prolapse more than 1 cm below hymen but no further than 2 cm less than TVL
4: complete procidentia

Question 2

pessary erosion

Answer 2

2-9%
Treat it by removing it for 2-4 weeks and local estrogen therapy

Question 3

workup for urinary incontinence

Answer 3

-history (ask about meds)
-UA
-physical exam (neuro exam, touch perineum and observe for introital or anal contraction, s2-4), look for prolapse, weight, estrogenization of pelvic tissue
-demonstration of stress incontinence (if not observed supine, then repeat standing with full bladder. if still neg, then urodynamic testing)
-if delayed by a few seconds, may be urge incontinence
-assessment of urethral mobility (q tip tst. look for hypermobility of urethra. At rest, <0 degrees (below the horizontal), with valsalva >30 degrees (above the horizontal)
-measurement of PVR (abnormal if >150. elevated PVR in the absence of prolapse is uncommon and should have urodynamic testing)

Question 4

who should undergo eval for microscopic hematuria and what is considered abnormal

Answer 4

microscopic hematuria as >3 RBCs per high power field
ACOG recommend that asx low risk never smoking women age 35-50 undergo eval only if they have >25 RBCs per high power field

Question 5

anti muscarinic meds for UUI

Answer 5

oxybutynin/tolterodine/solfenacin
Blocks parasympathetic M2/M3 receptors to inhibit involuntary detrusor contraction
SE: dry mouth (MC), dry eyes, constipation
Contraindications: narrow angle glaucoma, urinary retention, gastric retention

Question 6

beta 3 adrenoreceptor agonists for UUI

Answer 6

Mirabegron
Relaxes detrusor muscle and increases bladder capacity
SE: no different than placebo
Tachycardia, HA, diarrhea
contraindication: uncontrolled severe HTN, severe renal or liver dz

Question 7

complications of TVT vs TOT

Answer 7

Both: urinary retention, infection, hemorrhage, erosion, bowel injury
TOT: increase in groin pain, nerve injury, vaginal injury
TVT: increase in bladder perforation and urge incontinence

Question 8

what is OAB/UUI and treatments for it

Answer 8

detrusor muscle contracts when bladder isn’t full, urge to void, incontinence
antimuscarinic, beta adrenergic, vaginal estrogen botulinum toxin, sacral neuromodulation

Question 9

how to repair RV fisutla

Answer 9

wait 3-4 months for inflammation/infection to settle
estrogen cream if post menopausal
antibiotics if infection is present
liquid diet 24-48h before surgery
bowel prep (golytely and abx)
excise complete tract
place as many layers as feasible of intervening tissue (between two cavities involved, do not overlap) vicryl

3 layer closure. Close rectal mucosa (3-0vicryl) (or bladder mucosa if vesicovaginal), then muscularis (2-0 vicryl), then vaginal mucosa

post op wound care: stool softeners, sitz baths, clear liquids for 72h and low residue diet for 3-4w

Question 10

cystoscopy
retrograde pyelopgraphy
IVP

Answer 10

cystoscopy IDs intravesical fistula
retrograde: documents ureteral integrity
IVP: less useful for ID and disruption of urethral integrity

Question 11

treatment of vesico vaginal fistula

Answer 11

conservative: foley decompression for 4-6 weeks. If doesnt resolve, then place foley for 12 weeks after initial operation. observe up to 12w
surgery: three layer closure (excise tract, bladder submucosa, then bladder muscularis, then vag mucosal closure)
Latzko technique : fistula <1.5 cm, denude vaginal wall around fistual w/o excising it, layered closure over the fistula

Question 12

uretero-vaginal fistula management
1) low ureter injury site fistula
- if that doesn’t heal
2) high ureteral injury site fistula

Answer 12

Cystoscopy and CT urogram to ID fistula site and exclude bladder injury
1) ureteral catheter stenting (30% heal in 3-4 weeks), if not, then ureteroneocystotmy, CT urogram in 2-3 w post op
2) percutaneous nephrostomy tube for renal decompression. ureteral re implantation at 12 weeks
ct urogram 2-3 weeks post op

Question 13

sacrospinous ligament fixation and complications

Answer 13

vaginal apex sutured posterolaterally to the sacrospinous ligament (usually on R, sigmoid colon on left)
Less effective for ant wall support
post op: cystocele and stress incontinence common, enterocele, injury to pudendal nerve

Question 14

uterosacral ligament suspension and complications

Answer 14

opening of the vagina apex, dissect and ID the uterosacral ligaments. 2-3 permanent sutures placed through each uterosacral lig. elevates the vaginal apex towards the sacrum
complication: ureteral obstruction, kinking of ureters. if no bilateral jets, remove most lateral suture on that side. can injure sacral nerves

Question 15

abdominal sacral colpopexy

Answer 15

mesh graft to anterior and posterior dissections of the vaginal apex. Fixation of the graft to periosteum of the anterior sacrum
complications: bleeding from middle sacral vessels in the sacral periosteum, mesh erosion

Question 16

infected mesh exposure

Answer 16

mesh removal
treatment with 7d course of cipro or levofloxacin plus metronidazole

Question 17

intraoperative bleeding during sling procedure

Answer 17

generally from branches of vaginal artery and inferior vesical artery
Bleeding usually self limited
large bleeding in space of retzius is possible
acute hemodynamica decompression –> arterial bleeding –> laparotomy
consider embolization if HDM stable with large hematoma

Question 18

injury to bladder or urethra during sling

Answer 18

during passage of sling itself
deviate bladder toward midline during placement
perform diagnostic cystoscopy at the end
if bladder perf has occurred- remove perforating sheath or trocar, bladder completely emptied, trocar can be replaced while hugging post surface of pubic bone
repeat cystoscopy

Question 19

ureteral injury during sling

Answer 19

uncommon
during sling placement itself
diagnostic cystoscopy or by admin of IV sodium fluorescein

Question 20

bowel injury during sling

Answer 20

just be aware can happen

Question 21

urinary retention during sling

Answer 21

if placed under too much pressure
normal scar contraction during healing may produce over tightening of sling
dx: urethroscopy
usually resolves with exp management (foley cath for several days or intermittent self cath until PVR <150)
can observe up to 6 weeks
if complete retention or small voids with large pvrs, can loose after 1-2 weeks
re dissect sling site

Question 22

erosion of sling material into bladder or urethra

Answer 22

presents several weeks to months after procedure
urinary urgency, hematuria, bladder stones
cystoscopic resection
remove all sling material, local excision of erosion site in bladder, primary bladder repair with post op cath drainage

Question 23

treatment for painful bladder syndrome

Answer 23

dietary modifications and fluid management
amitriptyline (first line), then gabapentin, pregabalin, pentosan polysulfate (FDA warning for macular eye disease, restores GAG layer)
bladder training
PT
bladder instillations (DMSO, mechanism unknown)
electric nerve stimulation, sacral nerve modulation
pain meds (NSAIDs)
botox