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1

Define the terms “over active bladder” (OAB) and “urge incontinence” (UI). (2 marks)

OAB: frequent and urgent desire to pass urine that is difficult to control. Often results in increased frequency, passing small volumes and nocturia in the absence of infection or other pathology Urge incontinence: involuntary loss of urine associated with a strong desire to void

2

Complete the table below regarding the autonomic nerve supply to the bladder detrusor muscle. (2 marks) Sympathetic and PS = y axis Action on detrusor and Releases with neurochemical = x axis

Action on detrusor: - Sympathetic: Relaxation of detrusor and contraction of internal sphincter -Parasympathetic: Contraction Releases with neurochemical: - Sympathetic: Noradrenaline - Parasympathetic: Acetylcholine

3

 60 year old woman presents with symptoms consistent with OAB noticed increasingly over the last year. Clinical history confirms she experiences urge incontinence 3-4 times a week.

 List and justify the assessments you will make to further evaluate this patient’s symptoms/problem. For your answer you may use a table with the headings “assessment” and “justification”. (5 marks)

4

Outline six (6) management strategies available for urge incontinence in this patient. (6 marks)

  •  Lifestyle interventions

­Reducing daily fluid intake to 1-1.5L/day

­Avoiding tea, coffee and alcohol

­Dietary advice to improve constipation if present

­Wight loss if BMI >30

­Smoking cessation advice

  • Behavioural therapy

­Bladder drill. Timed voiding which aims to increase the intervals between voids and the bladder capacity, as well as reduce the number of urge incontinence episodes.

  • Physiotherapy

­Pelvic floor muscle training. Contract the pelvic floor muscles at least 8x on three occasions in a day.

­Vaginal cones

­Functional electrical stimulation

  • Medications

 Antimuscarinic drugs

­SE’s dry mouth, blurred vision, tachycardia, drowsiness and constipation

­Oxybutamin 5mg tdss

­Tolterodine 2mg bd

­Intravaginal oestrogens may improve symptoms of OAB in women with vaginal atrophy

 These meds can take up to 4 weeks to start working

  •  MDT review to consider any other invasive treatments as below

­Sacral nerve root stimulation

­Injection of botox

­Blocks the release of acetylcholine and when injected into the bladder wall using a flexible cystoscope can relax the overactive detrusor muscle.

5

 Both sacrospinous fixation and sacrocolpopexy can be performed to repair post hysterectomy vaginal vault prolapse.

Complete the following table using the headings provided to compare these operations.
(The two (2) benefits and two (2) risks must be different for each procedure). (6 marks)

6

7

Describe briefly the micturition reflex and the centres affecting micturition. (4 marks)

Bladder filling – activates stretch receptors – send afferent impulses via pelvic splanchnic nerves to spinal cord, triggering simple spinal reflexes. 

 

Pontine micturition centre and pontine storage centre control simple spinal reflexes to achieve micturition or storage.  

 

In micturition:

Spinal reflexes:

  1.  somatic - efferents from S2-S4 via pudendal nerve are inhibited – external urethral sphincter relaxes.
  2. ANS – SNS efferents via hypogastric nerve are inhibited, and PNS effferents via pelvic splanchnic nerve are promoted, resulting in contraction of detrusor muscle and relaxation of internal urethral sphincter. 

 

The pontine storage centre has the opposite effects on these reflexes resulting in storage of urine. 

8

Outline the principles of filling cystometry including the variables measured and aim of the test. (4 marks)

 

Aim of test is to characterize detrusor and urethral function during the filling phase via assessment of the pressure/volume relationship of the bladder during filling and voiding.  To determine relative contributions of USI and detrusor overactivity or other factors e.g. neurological disorders. 

 

Variables measured:

  1. Total bladder capacity (volume).
  2. Intra-abdominal, intravesical pressure (from which detrusor pressure can be calculated).
  3. Presence of – involuntary detrusor contraction (provoked or unprovoked), urgency or leakage
  4. Patient’s sensation of first desire to void and strong desire to void

 

Indications:

Failed conservative management.

Previous failed surgery.

To determine relative contributions of USI and DOA.

If surgery planned – assess most appropriate operation and likely success.

 

Procedure: 

Bladder emptied.  (post void residual can be measured here).  IDUC. 

Pressure catheters placed in bladder (measure IVP) and rectum (measure IAP).

Machine calibrated and checked.

Saline instilled into bladder.  IAP and IVP continuously measured.  Pt notes 1st desire to void and strong desire to void.  When sustained strong desire to void then filling stopped and total volume is measured.

 

9

A 60 year old patient is referred to you complaining of urinary frequency, urgency and urge incontinence. Physical examination is normal and an MSU is negative.

            Describe in detail the management options available for her. (7 marks)

  1. Lifestyle – weight loss if indicated, decrease intake of fluid, caffeine, EtOH.  Smoking cessation. 
  2. PFMT – some improvement in urgency symptoms.
  3. Bladder retraining – scheduled voids and aim to increase the interval between voids.  Needs to be performed for 6/12 for improvement.
  4. Pharmacological – pure antimuscarinics e.g.  tolteradine or agents with mixed action (antimuscarinic/Ca channel blocker/LA) e.g. oxybutinin.

- ADRs include dry mouth, constipation and visual disturbances.

  1. Other medical therapies – PV oestrogen if cocominant urogenital atrophy or desmopressin if nocturia (off-license).
  2. Inravesical therapies – botulinum toxin or capsaicin – block Ca-channel dependent release of Acetylcholine. 
  3. Neuromodulation – percuateous sacral neruomodulation or peripheral (posterior tibial).

 

Note: they don’t want surgical mgmt included in answer. 

 

 

10

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no co-morbidities.

 

  1. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

 

  • Severity of symptoms and impact on everyday life
  • Sexual activity
  • Previous prolapse or treatments tried
  • Menopausal symptoms
  • PMHx
  • Other gynae history or abdo surgery
  • Expectations and wishes regarding treatment

11

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

 

  1. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

ii) Comment on its usefulness in this setting. (2 marks)

  • Classifies prolapse into grades by measuring points in respect to hymen – minus is above, plus is below (Aa 3cm from ext urethral meatus, Ba leading edge of ant prolapse, C cervix/leading edge vault, D post fornix, Ap 3cm from hymen posteriorly, Bp leading edge of post prolapse, GH length genital hiatus, PB length perineal body, TVL total vaginal length)
    • 0 = no prolapse
    • 1 = prolapse to -1
    • 2 = prolapse lower than -1 but higher than +1
    • 3 = prolapse below +1 but higher than +(TVL-2)
    • 4 = complete procidentia, lower than +(TVL-2)

II):

  • System for objectively describing pelvic organ prolapse, especially helpful to compare pre and post treatment
  • Helps determine severity of prolapse to guide management decisions (however does not necessarily correlate with severity of symptoms)

 

12

13

On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.

 

  1. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)

 

Benefit

Risk

Vaginal pessary

  • No surgical/anaesthetic risk
  • Can be inserted immediately
  • Vaginal infection/ulceration
  • Not suitable for sexual function

SSF

  • Highly effective 90%
  • Quicker recovery
  • Buttock pain.   
  • Pudendal neurovascular damage

SCP

  • Most effective 90-98%
  • Can treat other intra-abdominal pathology
  • Sacral osteomyelitis
  • Rectal trauma

14

The RANZCOG Statement C-Gyn 20 “Prolpropylene Vaginal Mesh Implants for Vaginal Prolapse” (2013) is a guide to current practice.

 

  1. According to this statement, prior to undertaking a transvaginal mesh procedure, what issues should be addressed in the informed consent process regarding vaginal surgery for uterovaginal prolapse including those related specifically to the use of mesh (5 marks)?
     

  • Explain limited robust data on efficacy and safety of transvaginal mesh
  • Potential benefits and complications of prolapse surgery generally vs conservative treatment on status quo
    • Non-surgical: pessaries
    • No treatment (especially if mild, relatively asymptomatic prolapse)
  • Potential benefits and complications of transvaginal mesh specifically:
    • Mesh exposure/erosion
    • Vaginal scarring/strictures
    • Fistula formation
    • Dyspareunia
    • Chronic pelvic pain – which may persist even after mesh removal
  • Discuss surgical alternatives eg conventional native tissue repair or abdominal sacrocolpopexy/sacrospinous fixation
  • The surgeons experience with mesh as evidenced by logbooks/training/peer review

15

  1. According to the above statement:
  1. What is the current evidence regarding the benefits (if any) of transvaginal mesh versus native tissue prolapse repair with respect to procedure success/longevity for the anterior compartment, posterior compartment and vault? (3 marks)

  • Anterior
    • Mesh more successful than native tissue prolapse repair - 10% vs 30% failure rates
    • Reoperation rates lower (?)
  • Posterior
    • No difference in success
    • Reoperation rates similar (?)
  • Vault
    • Mesh less successful than native tissue prolapse repair eg with SSF/sacrocolpopexy
    • Reoperation rates similar (small numbers in study)

 

16

  1. What are the complications associated with the use of transvaginal mesh? (3 marks)

  • Mesh erosion
  • Vaginal scarring/strictures
  • Dyspareunia
  • Chronic pelvic pain – which may persist even after mesh removal

 

17

  1. According to the above statement, caution should be exercised in using transvaginal mesh implants in which patients? (4 marks)

  • Age <50
  • Chronic pelvic pain
  • Primary prolapse repair
  • Posterior prolapses without significant apical descent
  • Postmenopausal women unable to use ovestin (as first line management mesh erosion)
  • Mild prolapses (less than grade 2)

18

A 45 year old woman with a body mass index (BMI) of 35 kg/m2 presents to the gynaecology clinic with symptoms suggestive of stress urinary incontinence.

 

a.         How would you make the diagnosis of ‘pure’ stress incontinence on history (3 marks), examination (1 mark) and investigation (1 mark)?

 

  • History
    • Involuntary urine leakage with cough/sneeze/strain/exertion
    • Not associated with urgency, frequency
    • Usually small – mod volumes of leakage
    • Absence of leakage at rest
  • Exam
    • May see leakage with coughing/straining
    • Otherwise usually normal exam
  • Investigation
    • Urodynamics –  observation of leakage of urine associated increased intraabdominal pressure in the absence of an involuntary detrusor contraction. 
    • Bladder diary

19

List six factors that predispose to genuine stress urinary incontinence. (3 marks)

  • Increasing age
  • Parity
  • Vaginal births
  • Obesity
  • Chronic cough
  • Postmenopausal

20

Describe two non‐surgical interventions that can benefit pure stress incontinence symptoms. (2 marks)

  • Pelvic floor exercises - best if taught by physio, do 3 times per day for at least 3 months. Involves awareness of pelvice floor and ability to isolate and contract.
  • Lifestyle interventions – reduction in fluid intake, reduce caffeinated drinks, weight loss

 

21

Describe in detail the operative technique of a tension‐free vaginal tape (TVT) procedure. Assume appropriate sedation or anaesthesia and sterile preparation has been performed. (5 marks)

  • Prophylactic antibiotics, Teds
  • Lithotomy position
  • IDC – 18G with rigid guide
  • Local anaesthetic diluted with saline
    • Over mid urethra vaginally
    • Retropubic hydrodissection – start just above symphysis, 2cm from midline on either side, aiming towards fornix on either side to level of urogenital diaphragm with 20-30mls
  • Stab incisions through skin just above symphysis 2cm from midline on either side
  • Vertical incision 1.5cm from external urethral meatus, approx. 2cm long over mid urethra
  • Dissection of vaginal mucosa from pubocervical fascia with fine scissors towards inferior pubic ramus to level of urogenital diaphragm
  • Rigid catheter used to move bladder away then trocar with tape inserted through vaginal incision and previously created tunnel, through urogenital diaphragm aiming towards stab incision, do both sides
  • Remove IDC
  • Cystoscopy – check no bladder injury from trocar/tape
  • Bring trocars through skin, cut
  • Tension tape eg over Hegar 8 dilator 
  • Remove plastic sleeves
  • Cut tape below level of skin
  • Ensure vaginal skin freed up over tape, close with interrupted absorbable sutures
  • Close stab incisions with interrupted suture, apply dressings
  • Can remove IDC, ensure postvoid residuals measured, may require reinsertion if high, or if thought high risk of retention, leave IDC on free drainage overnight and TROC the following morning

22

a.  List causes of a vesico-vaginal fistula. (4 marks)

Obstetric fistula:

- Obstructed labour

- Operative vaginal delivery and MROP

- After Caesarean section, peri-partum hysterectomy, and uterine rupture at term

Post-surgical fistula:

- Direct injury at dissection or crush injury, cautery, or suture placement (e.g. at hysterectomy)

Radiation therapy: due to a small vessel endarteritis that impairs the vascular supply of tissues and impairs the healing from surgical procedures

Inflammation: PID, diverticultis, or IBD can cause fistulae. Other severe pelvic pathology such as cancer can also be a cause

Penetrating injuries and retained foreign bodies

Congenital anomaly including a fistula

23

A 45 year old woman underwent an abdominal hysterectomy. One week later she attends your clinic complaining of a watery loss on her underwear.

b.  How would you diagnose a vesico-vaginal fistula? (8 marks)

History:

  • Reason for hysterectomy: for benign or malignant disease
  • Immediate post-operative course: any severe abdominal pain, trouble with passing urine, haematuria, ascites, or other reasons to suspect a bladder or ureteric injury?
  • Symptom onset and duration
  • Volume of leakage: changing heavy pads frequently?
  • Colour and smell of leakage
  • Flow characteristics of leakage: continuous, intermittent, and flow, precipitating factors e.g. cough
  • Bowel habit
  • Associated stress or urge incontinence pre-or post procedure ‘
  • Associated symptoms such as pain, fever, urinary symptoms, vaginal bleeding
  • Smoking status
  • Past medical, surgical, gynae and obstetric history, radiation or trauma
  • Review notes from previous admission and for the surgery

 

Examination:

  • Observations (HR, BP, Temp, RR, SAO2) and BMI
  • Abdominal examination: ascites or masses present? Pelvic examination?
  • Pelvic examination: gentle examination with a split speculum looking at the integrity of the vaginal cuff-  the entrance to the fistula is typically in the upper 1/3 of the vagina or at the cuff- most are obvious on examination, urine leakage may be seen or a hole may be present, smell of urine may also be present 
  • PR exam to check integrity of anal sphincter
  • EUA can be performed if this is not well-tolerated

Investigations (if no obvious fistula on clinical examination):

  • 3 swab or Tampon test: place a tampon into the vagina and fill the bladder via a bladder catheter with methylene blue or indigo carmine. The tampon should be checked for dye after a cough or Valsalva manoeuvre. Blue staining on the tampon from the vaginal apex indicates a vesico-vaginal fistula
    • Clear urine on the tampon/last swab indicates a potential ureterovaginal fistula
  • MSU for urinalysis and culture
  • Cystoscopy: assess the bladder for the location of the injury, any stitches that may be present and the number of openings into the bladder. May need to be carbon dioxide cystoscopy after filling the vagina with saline to look for bubbles
  • Other tests such as retrograde pyelography, CT IVurogram with contrast, pelvic MRI can be used if these tests do not reveal the location of the fistula and to assess ureteral integrity
  • Consider EUA if examination difficult for the patient to tolerate- may need to have lacrimal probes to demonstrate a very small fistula

24

.  List the treatment options if a vesico-vaginal fistula is diagnosed. (3 marks)

Non-surgical

  • Continuous urinary drainage with a bladder catheter may be effective in a small number of women with a small fistula that is recognised early (within 2-3 weeks post-op)- the fistula may close spontaneously 
  • Treat UTI if present, treat vaginitis if present
  • Incontinence pads and barrier creams can be used if continued leakage to protect the skin from urine dermatitis

Surgical

  • Fistula repair can be early (if tissue is healthy) but delayed is preferred (6-12 weeks post-op to allow for healing and reduction in granulation tissue/necrosis)
  • She should be referred early to experienced clinicians  as the first repair has the highest chance of closure.
  • Choice will be determined by severity and location of fistula
  • An episiotomy may be required to enable adequate exposure for a vaginal repair
  • Traditional repair (flap splitting technique) is performed in layers with absorbable sutures. There is wide lateral dissection to expose healthy vaginal tissue and to create a flap to cover the defect without tension, the tract is dissected and the healthy tissue is repaired in layers. The ureters may need to be stented pre-procedure as they are often close to the repair site. After suturing is complete use methylene blue to ensure repair is water tight, then perform cystoscopy and check ureteric patency
    • Does not shorten the vagina and has a success rate equivalent to the Latzko procedure
  • The Latzko method would be appropriate if her fistula is small. A foley catheter is placed inside the fistula, the surrounding vaginal is excised in quadrants (the vesical edges of the fistula are not debrided). A 3 layer closure is then completed over the area. Urothelium will overgrow the defect.
  • IDC in for at least 10-14 days week for bladder rest- may need longer drainage depending on the type and location of repair
    • Must use a large-bore catheter to prevent blockages
  • Follow up in urology with cystogram +/- cystoscopy before IDC is removed
  • Complex fistula repair:
    • Complex and scarred fistulas may need to be repaired abdominally using a trans-vesical approach (beware the ureters!)- this may be necessary in a post-hysterctomy vault fistula that may not come down easily
    • Grafts may be needed to cover the area in a large fistula eg a Martius fat graft or a muscle graft (Mackenrodt technique uses part of the gracilis)

25

Feb 2017 Question 11

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no comorbidities.

a. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

  • Urinary incontinence- stress, urge or mixed in continence
  • Symptoms of menopause- vasomotor symptoms, vulvovaginal atrophy
  • Obstetric history- number of children and mode of delivery (CS vs vaginal delivery)
  • Sexual history- whether current sexually active/prolapse interfering with sexual activity
  • Her preferences with regards to management options eg conservative, medical, surgical
  • Previous treatments for prolapse and other previous surgery
  • Chronic cough, constipation
  • Smoking

26

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

b. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

Staging system which allows objective quantification of prolapse.

Point of reference is the hymenal ring: counted as 0

  • Point Aa and Ap are 3cm into the vaginal from the hymenal ring: - 3
    • Corresponding points Ba and Bp which define the most dependent part of the prolapse, if there is not prolapse they are also -3
  • C = cervix or vaginal cuff
  • D= posterior fornix, absent after hysterectomy
  • Total vaginal length- from the hymen to the posterior fornix
  • Genital hiatus- from the bottom of the urethra to the posterior forchette

27

ii) Comment on its (POP-Q) usefulness in this setting. (2 marks)

 

  • Gives objective quanitification of prolapse
  • Good intra- and inter-observer consistency of measurement and definition of prolapse
  • Allows objective comparison of pre- and post-surgical state

28

On examination you find that the woman has a prolapse of the vaginal vault (middle compartment prolapse) presenting 2cm beyond the introitus when at rest.

c. Describe two benefits and two risks for each of one non-surgical and two surgical treatment options available for this condition. You do not need to describe the surgical methodology. You may use a table. (6 marks)

 

Benefits

Risks

Vaginal pessary

Outpatient procedure

Does not require surgery

Cheaper

Patient can remove and replace

Pessary erosion

Higher failure

Sacrocolpopexy (laparoscopic or abdominal)

Low risk of reoperation

Treat concurrent abdominal pathology

Mesh exposure

Sacral osteomyelitis

Sacrospinous fixation

Vaginal surgery with shorter operating time

Buttock pain

Bleeding risk from inferior gluteal artery

Higher recurrence risk

29

A 55 year old woman is referred by her GP with symptoms of prolapse. She had a vaginal hysterectomy 10 years ago for menorrhagia. For the past 6 months she has noted a vaginal bulge which is getting bigger. Her bladder and bowel function are normal and there is no pain, bleeding or discharge. She is on no medication and describes herself as “fit and active”. She has no co-morbidities.

 

  1. What additional information elicited from her gynaecological history will influence her treatment options? (5 marks)

  • Severity of symptoms and impact on everyday life
  • Sexual activity
  • Previous prolapse or treatments tried
  • Menopausal symptoms
  • PMHx
  • Other gynae history or abdo surgery
  • Expectations and wishes regarding treatment

30

You proceed to examine the patient and quantify her prolapse using the Pelvic Organ Prolapse Quantification System (POP-Q).

 

  1. i) Outline the POP-Q quantification system (POP-Q). (2 marks)

  • Classifies prolapse into grades by measuring points in respect to hymen – minus is above, plus is below (Aa 3cm from ext urethral meatus, Ba leading edge of ant prolapse, C cervix/leading edge vault, D post fornix, Ap 3cm from hymen posteriorly, Bp leading edge of post prolapse, GH length genital hiatus, PB length perineal body, TVL total vaginal length)
    • 0 = no prolapse
    • 1 = prolapse to -1
    • 2 = prolapse lower than -1 but higher than +1
    • 3 = prolapse below +1 but higher than +(TVL-2)
    • 4 = complete procidentia, lower than +(TVL-2)