Urogyn

Question 1

Pubocervical fascia damage can result in…

Answer 1

Cystocele or urethrocele

Question 2

Endopelvic fascia damage of the rectovaginal septum can result in

Answer 2

Rectocele

Question 3

Injury or stretching of the uterosacral and cardinal ligaments can result in

Answer 3

Uterine prolapse

Question 4

What can happen after hysterectomy?

Answer 4

Enterocele or vaginal vault prolapse

Question 5

Common conditions that compromise pelvic support

Answer 5

• Chronic cough eg. COPD
• Pregnancy and subsequent delivery
• Chronic heavy lifting
• Connective tissue disorders
• Atrophic changes due to aging or estrogen deficiency

Question 6

Risk factors of pelvic organ prolapse?

Answer 6

• AGE
• Parity
• Menopause
• 4x with one vaginal deliveries, 8x with two
• Obstructed labor or traumatic delivery
• Elevated intra-abdominal pressure (chronic)

Question 7

When a woman with prolapse reports that her stress incontinence has improved…

Answer 7

…it’s usually from a worsening prolapse. As support for anterior vaginal wall weakens and the bladder descends, there’s a kink into the urethra causing MECHANICAL OBSTRUCTION.

Question 8

What do women with prolapse-related defecatory issues do to compensate?

Answer 8

“Splinting” by applying pressure on the perineum or posterior vaginal wall

Question 9

What is complete procidentia?

Answer 9

Complete eversion of the vagina with the entire uterus prolapsing outside it.

Question 10

Scoring system?

Answer 10

Baden-Walker Halfway System- relates 4 points to prolapse’s relation to hymen as the point of reference

Pelvic organ prolapse quantitative scale (POP-Q)- focuses on the physical extent of the vaginal wall prolapse (not which organ is prolapsing)

Question 11

Diagnosis?

Answer 11

Cystoceles and urethroceles- urine cultures, cystoscopy, urethroscopy, urodynamic studies

Rectocele- r/o obstructive lesions via anoscopy or sigmoidoscopy

Question 12

Differential diagnosis for cystocele and urethrocele?

Answer 12

RARE IN COMPARISON…

• Urethral diverticula
• Gartner cysts
• Skene gland cysts
• Tumors of the urethra/bladder

Question 13

Differential for rectocele?

Answer 13

Obstructive lesions of colon and rectum…

• Lipomas
• Fibromas
• Sarcomas

Question 14

Treatment options

Answer 14

1) Expectant management
2) Conservative- Kegel exercises and pessaries
3) Surgical repair
4) LOW-DOSE VAGINAL ESTROGEN

Question 15

What do you do in a pregnant woman with prolapse?

Answer 15

PESSARY

Note: incontinence often resolves after recovery form the peripartum period

Question 16

Risks of pessary?

Answer 16

Pain, ulcerations, bleeding, leukorrhea (white or yellowish discharge), infection

Question 17

If you do a hysterectomy, what else is needed?

Answer 17

Apical suspension procedure (of the vaginal vault)

Question 18

Poor surgical candidates who no longer desire intercourse?

Answer 18

Colpocleisis

Question 19

Another thing that improves pelvic floor pathology?

Answer 19

WEIGHT LOSS

Question 20

Who is more likely to have a successful pessary fitting

Answer 20

Long vagina and narrower introitus

Question 21

Stress incontinence

Answer 21

Intra-abdominal pressure increases.

Usually with hyper mobile urethra.

The detrusor muscle hasn’t contracted

Question 22

What do a small proportion of stress incontinence ppl have?

Answer 22

Intrinsic sphincter deficiency (internal sphincter muscle is weak)

Question 23

Treatment for stress incontinence?

Answer 23

Lifestyle changes

Surgery! Resuspend the hyper mobile urethra with abdominal retro-pubic urethropexies, bladder neck slings, tension-free midurethral slings

For ppl with intrinsic sphincter deficiency, can inject bulking agent like collagen around the urethra.

Question 24

Urge incontinence

Answer 24

Detrusor is overactive (usually but not necessarily). “DETRUSOR INSTABILITY”

Involuntary urgency, frequency, nocturia. Dribbling or leaking triggered even by seeing bathroom.

IDIOPATHIC!

Question 25

Urge incontinence treatment?

Answer 25

• Lifestyle changes
• Anticholinergic drugs- bladder capacity increases and the urgency decreases
• Sacral neuromodulation for the retention sx
• Posterior tibial nerve stimulation for the frequency and urgency sx
• Botox (NOT FDA approved)
• Augmentation cystoplasty (rare)

Question 26

Important to remember about anticholinergic drugs?

Answer 26

Effect may take up to 4 wks.

CONTRA for gastric retention and angle closure glaucoma
CAUTION in dementia

Question 27

Names of the anticholinergic drugs

Answer 27

Oxybutynin
Tolterodine
Fesoterodine
Solifenacin
Trospium
Darifenacin

Question 28

Overflow incontinence?

Answer 28

• Underactive or acontractile detrusor muscle (constant dribbling)
• Bladder outlet obstruction
• Postoperative overdistension

Question 29

Treatment of overflow incontinence?

Answer 29

• Striated muscle relaxants (diazepam, dantrolene)

- alpha blockers (prazosin…reduce urethral closing pressure)

Question 30

Bypass incontinence?

Answer 30

Urinary fistula–> continuous incontinence

Question 31

Ureterovaginal fistula

Answer 31

Usually due to devascularization than direct injury, happen in radical hysterectomies (rare)

Diagnose by giving IV indigo carmine which passes thru kidneys and would stain tampon in the vagina

Question 32

When do you repair a post-surgical fistula?

Answer 32

In 3-6 months

Question 33

How do you ID number and location of fistulas?

Answer 33

Cystourethroscopy

Voiding cystourethrogram