O&G:Urogynae Flashcards
(33 cards)
What are the two main causes of incontinence in females?
1) Uncontrolled increases in detrusor pressure
- Increased bladder pressure beyond that of normal urethra, most common cause OAB
2) Increased intrabdominal pressure
- Most common cause is urinary stress incontience
What is urinary stress incontinence?
Involuntary leakage of urine on effort or exertion eg. sneezing or coughing. aka urodynamic stress incontinence.
Causes of urinary stress incontinence?
- Pregnancy
- Vaginal delivery
- Prolonged labour
- Forcep delivery
- Obesity
- Age
- Prev hysterectomy
- Prolapse usually coexists
Mechanism of urinary stress incontinence?
Increased abdominal pressure compresses the bladder, but weak sphincter causes incontinence.
Clinical features of urinary stress incontinence?
Frequency, urgency, urge incontinence, faecal incontience (due to childbirth injury)
On examination of stress incontinence?
Sims speculum: Cystocele, urethrocele
Leakage with coughing
Palpate abdomen to exclude distended bladder
Investigations for stress incontinence/
Urine dipstick to exclude infection
Cystometry to exclude OAB
What is the conservatiive management of stress incontinence?
- Pelvic floor muscle training for minimum 3 months. At least 8 contractions 3 times a day
- Vaginal cones - held in position by voluntary muscle contraction
- Lose weight, decrease excessive fluid intake, address underlying cough eg smoking
What is the pharmaceutical management of stress incontinence?
- Duloxetine: an SNRI, enhances urethral striated sphincter activity.
S/e: Nausea, dyspepsia, dry mouth, dizzy, insomnia, drowsy
What is the surgical management of stress incontinence?
- Tension free vaginal tape
- Transobturator tape
- Injectable peri-urethral bulking agents
What is overactive bladder?
Urgency, with or without urge incontinence, usually with frequency or nocturia, in the absence of proven infection.
Causes of OAB?
- Mostly idiopathic
- Bladder neck obstruction, post USI operation
- Underlying neuropathy eg.ms
- Detrusor overactivity
What is detrusor overactivity?
A urodynamic diagnosis characterised by involuntary detrusor contractions during the filling phase. Either spontaneous or provoked eg. coughing
Clinical features of OAB?
- Urgency
- Urge incontinence
- Frequency
- Incontinence
- Nocturia
- Stress incontinence
- Leak at night or at orgasm
- Faecal urgency
- Hx of childhood enuresis is common
Investigations of OAB?
Examination: often normal (may be incidental cystocele)
Urinary diary:
- Frequent passage of small volume of urine, especially at night.
- High intake of caffeine
Cystometry:
- Contractions on filling or provocation
- Indicated after failure of lifestyle changes and drug management
Conservative management of OAB?
Conservative:
- Reduce fluid intake and caffeine
- Bladder training
Drug management of OAB?
Drugs:
- Anticholinergics/antimuscarincs - block detrusor smooth muscle action eg Oxybutynin s/e dry mouth
- Oestrogens - in post-meno it reduces sx of vaginal atrophy and decreases sx
- Botulinum toxin a - blocks the neuromuscular transmission, so weakens detrusor. s/e retention, voiding dysfunction
Other managemnt of OAB?
Other tx:
- Neuromodulation and sacral nerve stimulation
- Surgery - Clam-augmented iliocystoplasty
What is a level one prolapse?
Cervix and upper 1/3rd of vagina
- Cardinal ligament
- Uterosacral ligament
What is a level two proplapse?
Midportion of vagina
- Endopelvic fascia attach vagina laterally to side walls
What is a level three prolapse?
Lower 1/3rd of vagina
- Supported by levator ani muscles and the perineal body
What is a Urethrocele?
Prolapse of lower anterior vaginal wall involving urethral only
What is a Cystocele?
Prolapse of upper anterior vaginal wall involving the bladder
What is a Cystourethrocele?
Prolapse involves bladder and urethra
