Post Menopausal Disorders

Question 1

PMB

Answer 1

Approximately 10% of women with PMB have Gynaecological Cancers; Mostly Endometrial
TV USS and measurement of Endometrial Thickness for Rick Assessment; If <4mm, less than <1% likely is Endometrial Ca
o Although high NPV, if Recurrent PMB should have Hysteroscopy
Other causes include Endometrial Atrophy, Vaginal Atrophy, Uterine Fibroids and Polyps, Infection, Pelvic Trauma or Endometrial Hyperplasia

Question 2

Pelvic Organ Prolapse

Answer 2

Protrusion of Uterine and/or Vagina beyond normal anatomical confines; Bladder, Urethra, Rectum and Bowel are often involved

Question 3

Types of Prolapse

Answer 3

Classified Anatomically – Cystocoele (Anterior Vaginal Wall involving the Bladder; Might be associated with Urethral =Cystourethrocoele); Uterine/Apical Prolapse, Enterocoele (Upper Posterior Wall of Vagina) and
Rectocoele (Posterior Wall of Vagina involving Anterior Rectum)

Question 4

Grading of Prolapses

Answer 4

Baden-Walker (Grade 1 =Lowest point Halfway-down Vaginal Axis, Grade 2 =Lower point to level of Introituse, passes through on Straining and Grade 3 =Lowest part beyond and lies outside Vagina, also =Procidentia)

Question 5

Presentation of Prolapse

Answer 5

Dragging Sensation, Discomfort, Heaviness (‘Feeling a lump coming down’); Dyspareunia, Difficulty inserting tampons, Discomfort and Backache
• Symptoms tend to worsen with Prolonged standing and towards end of day
• Mucosal Ulceration, Lichenification can occur leading to Bleeding/Discharge
• Pelvic Examination, Traction if absolutely necessary; May be demonstrated on Standing or Straining; Assess Pelvic Floor Strength (Modified Oxford)

Question 6

Signs of Cyst urethrocele

Answer 6

Urgency, Frequency, Incomplete Emptying, Retention or Reduced Flow;

Question 7

Signs of Rectocele

Answer 7

Constipation, Tenesmus

Question 8

Investigating Prolapse

Answer 8

• Ultrasound to exclude masses if suspected clinically; Urodynamics if Incontinence
• ECG, CXR, FBC U/Es XM to assess Fitness for Surgery

Question 9

Prevention of Prolapse

Answer 9

• Reduction of Prolonged Labour and Trauma from Instrumental Delivery
• Postnatal Pelvic Floor Muscles
• Weight Reduction, Management of Chronic Constipation and Cough

Question 10

Conservative Management of Prolapse

Answer 10

Physiotherapy – Mild prolapse in younger women who might not desire Intravaginal devices and not yet willing to consider definitive surgery
o Pelvic Floor Exercises – Most effective when taught; Unlikely to benefit older women with significant prolapse
o Biofeedback and Vaginal Cones improve outcomes
• Intravaginal Devices – Pessaries (Lasts 6/12, might be given with Topical Oestrogen)

Question 11

Surgical Management of Anterior Repair: Anterior Colporrhaphy

Answer 11

Anterior Colporrhaphy for Cystocoele – Longitudinal Incision on Anterior Vaginal Wall; Dissection from the Pubocervical Fascia and Buttressing Sutures placed; Surplus Vaginal Skin
is excised and closed; Either Regional or GA, but can also be done LA
o Low Morbidity but Recurrence up to 30%; Might be due to failure to identify •

Question 12

Surgical Management of Anterior Repair: Paravaginal Repair

Answer 12

Paravaginal Repair (Abdominal Approach for Anterior Defect) – Pfannenstiel Incision and Bladder Mobilised Medially; Lateral Sulcus of Vagina Elevated and Reattached to Pelvic Sideway using Interrupted Sutures
o Can also be done Laparoscopically; 70 – 90% Cure rate
o Not commonly performed; Might have higher recurrence rates than reportedco-existing Apical/Uterine Defect

Question 13

Posterior Repair

Answer 13

Correction of Rectocoele and Deficient Perineum; Repair of Rectovaginal Fascial Defect and Removal of Excess Skin

Question 14

Surgical Management for Uterovaginal and Vault Prolapse

Answer 14

Vaginal Hysterectomy
Hysteropexy – Uterus-Preserving; Uterus and Cervix attached to Sacrum using Bifurcated Mesh; Stronger support when compared to Hysterectomy
• Sacrospinous Ligament Fixation – Suturing Vaginal Vault to Sacrospinous Ligaments using Vaginal Approach;
Success rate 70 – 85%; Risk of Dyspareunia due to change in Vaginal Axis
• Sacrocolpoplexy – Vault attached to Sacrum using Mesh; Higher success rate (90%)

Question 15

Urinary Incontinence

Answer 15

=Complaint of Involuntary Leakage of Urine

Question 16

Stress Incontinence

Answer 16

Involuntary Leakage on Effort/Exertion, Sneezing or Coughing; Arises commonly due to Urethral Sphincter weakness

Question 17

Urge Incontinence

Answer 17

Accompanied by or Immediately Preceded by strong desire to Void
o OAB – Urgency, Urge Incontinence, Frequency plus Nocturia

Question 18

Mixed Incontinence

Answer 18

Urgency plus Exertion/Effort/Sneezing/Coughing; Usually one type predominant

Question 19

Overflow Incontinence

Answer 19

Bladder becomes Large and Flaccid with little/no Detrusor Tone or Function
o Diagnosed when Urinary Residual >50% capacity; Bladder simply leaks when full

Question 20

Continuous Incontinence

Answer 20

Classically associated with Fistula or Congenital Abnormality (e.g. Ectopic

Question 21

Other causes of incontinence

Answer 21

UTI, Medications, Immobility, Cognitive Impairment

Question 22

Urinary Symptoms

Answer 22

Daytime Frequency, Nocturia (Waking up at night needing to void); Nocturnal Enuresis (Incontinence when asleep)
Urgency, Voiding difficulties, post voiding symptoms, haematuria
Absent or Reduced Bladder Sensation, Bladder Pain, Urethral Pain
o Dysuria =Pain in Bladder or Urethral when passing urine; Most frequently assoc UTI

Question 23

Urgency

Answer 23

Most frequently secondary to Detrusor overactivity, but also can occur due to Inflammatory conditions of the bladder

Question 24

Voiding difficulties

Answer 24

suggestive of Obstruction, Detrusor Underactivity etc
o Hesitancy (Difficulty initiating), Straining to void, Slow or Intermittent stream

Question 25

Post-voiding symptoms

Answer 25

Feeling of incomplete emptying, Terminal Dribble (Prolonged final part of Micturition), Post-micturition Dribble

Question 26

Investigating Urinary Symptoms

Answer 26

Urinalysis, Urine MC+S if Dip positive; Bladder Ultrasound post-void • Cystourethroscopy – Visualisation of the Lower Urinary Tract; Rigid or Flexi Cystoscope; Can obtain Bladder Biopsy • Imaging – Ultrasound KUB, Plain Film for FBO and Stones, Contrast CT KUB, IV Urography (CT KUB more accurate and rapid), MCUG (Demonstrates Fistula, Reflux and Anatomical Abnormalities), MRI (Mainly for Tumour staging) • Urodynamics – Uroflowmetry (Volume over time), Cystometry (Bladder Pressure), Videourodynamics (Fluoroscopic Imaging plus Cystometry), Ambulatory Urodynamics

Question 27

Indications for cystourethroscopy

Answer 27

o Indications – Recurrent UTI, Haematuria, Bladder Pain, Suspected Injury or Fistula, Exclude Stone disease or Tumour, or Suspected Interstitial Cystitis o If Interstitial Cystitis suspected, Second-look Cystoscopy should be performed after initial distention to check for Glomerulations or Petechial Haemorrhages

Question 28

Management of Stress Incontinence: Conservative

Answer 28

Weight loss if BMI>30, Smoking Cessation, Treatment of Chronic Cough or Constipation; Pelvic Floor Muscle Exercises, Biofeedback, Vaginal Cone s • Pharmacological Management – Duloxetine (SNRI that increases Urethral Striated Sphincter activity centrally; Efficacy disappointing and significant SE (Nausea, Dyspepsia, Dry mouth, Insomnia, Drowsiness, Dizziness); Not first line

Question 29

Indications: Surgical Management of Stress Incontinence

Answer 29

Considered when conservative measures failed, or QOL compromised; Important to be clear about diagnosis as Detrusor overactivity (Urge incontinence) can be made worse with surgery

Question 30

Surgical Management of Stress Incontinence

Answer 30

Peri-urethral Injection – Bulking agents injected under LA; May be appropriate for women who are frail, older or unfit for surgery, or women who have yet to complete family • Tension-free Vaginal Tape (TVT) – Polypropylene tape under Mid-urethra through small Vaginal incision; Cystourethroscopy to ensure no damage to Bladder or Urethra o 5 – 10% risk to Bladder injury; Bleeding, Infection, Tape Erosion can occur o Cure rate 82 – 98% (Mean 94%) • Transobturator Tape – Through Obturator Foramen instead; Low risk of Bladder injury but higher risk of Nerve Trauma; 20% have chronic groin pain • Culposuspension – Compression of Vaginal Wall against Bladder Neck/Urethra

Question 31

Overactive Bladder Syndrome

Answer 31

Chronic; Defined as Urgency ± Urinary Incontinence usually with Frequency and Nocturia • Second most common cause of Incontinence behind SUI; Most common in older women

Question 32

Causes of OAB

Answer 32

Idiopathic in most cases; Can be secondary to Pelvic or Incontinence Surgery; Neurogenic Detrusor Overactivity can be found in MS, Spinal Bifida and UMN lesions

Question 33

OAB Triggers

Answer 33

Can be triggered by Temperature, Intra-abdominal pressure (Misleading to diagnosis of SUI); QOL can be significantly impaired by unpredictability and volume of leakage

Question 34

Investigating OAB

Answer 34

Investigation – Culture is mandatory; Frequency and Volume Charting, Urodynamics o Diagnosis by Urodynamic assessment o Need to exclude other factors e.g. Metabolic Abnormalities (DM, Hypercalcaemia), Physical causes (Prolapse, Impaction) or other Urinary Pathology (UTI, IC)

Question 35

Conservative Management of OAB

Answer 35

Fluid intake control, Avoid caffeine, diuretics; Bladder Retraining

Question 36

Pharmacological Therapy

Answer 36

Anticholinergics e.g. Oxybutynin, Solifenacin; (Relax Detrusor by blocking Parasympathetic input; SE: Dry mouth, Constipation, Nausea, Dyspepsia, Blurred Vision (Loss of Accomodation), Palpitation and Arrythmia CI: Acute Glaucoma, MG, Retention or Obstruction, Severe UC, GI Obstruction o Intravaginal Oestrogens – If Atrophic Vaginitis; Often helps symptoms

Question 37

Other therapies for OAB

Answer 37

``` Botox A (Cystoscopic Injection into Detrousor under LA) – Can lead to Retention requiring Intermittent self-cath in 5-10%; Repeat Injections 6-12/12ly • Neuromodulation – Continuous Simtulation of S3 nerve root; 50% Success rate ```

Question 38

Surgery for OAB

Answer 38

Surgery for Debilitating symptoms, failed all other therapy; E.g. Detrusor Myomectomy, Augmentation Cystoplasty of limited efficacy; Permanent Diversion for Intractable disease