Urogynae Flashcards
Management Pathway of Overactive Bladder
Conservative: bladder training, treatment of vaginal atrophy, reduction of caffeine, weight loss
Medical:
Anticholinergics
1st: Oxybutynin (not if elderly/frail), Solifenacin
2nd: Tolteridone
3rd: Darifenacin
Need 4 week trial to assess benefit
Can have transdermal if oral not tolerated
Mirabegron (b3-adrenregic agonist)
Reduce dose in renal/liver impairment
If nocturnia - desmopressin
Duloxetine
Intravaginal oestrogen
Surgical:
Assessment for detrusor overactivity - can be treated with Botox A injections (200 units although 100 units may be affected)
Percutaneous sacral nerve stimulation - good evidence of benefit
Percutaneous posterior tibial nerve stimulation - not enough evidence currently, but could be fitted in OP setting, 12 weeks of treatment
Augmentation cystoplasty
Urinary diversion
Long term catheter
What are specific risks when consenting for vaginal surgery for prolapse?
FREQUENT:
-Pain (post op and dyspareunia)
-Bleeding
-Wound infection
-Urinary infection, retention, frequency
SERIOUS:
-damage to bladder/urinary tract, two women in every 1000 (uncommon)
● damage to bowel, five women in every 1000 (uncommon)
● excessive bleeding requiring transfusion or return to theatre, two women in every 100 (common)
● new or continuing bladder dysfunction (variable – related to underlying problem)
● pelvic abscess, three women in every 1000 (uncommon)
● failure to achieve desired results; recurrence of prolapse (common)
● although venous thrombosis (common) and pulmonary embolism (uncommon) may contribute to mortality,
the overall risk of death within 6 weeks is 37 women in every 100 000 (rare).
When discussing risk with a patient, what is meant by….
Very common
Common
Uncommon
Rare
Very Rare
Very common - 1/1 to 1/10
Common 1/10 to 1/100
Uncommon 1/100 to 1/1000
Rare 1/1000 to 1/10000
Very Rare Less than 1/10000
What is the evidence about continence surgery at the time of pelvic organ repair?
Women with POP and no stress incontinence:
Almost 1/3 of women have post-op SUI if dual procedure performed.
Synthetic mid-urethral slings had evidence which could improve continence symptoms but no longer routinely offered
In women with POP and stress incontinence: Good evidence that performing both surgeries will reduce SUI symptoms post-op, however many women will report improvement in symptoms based on POP surgery alone
In women with incontinence and asymptomatic prolapse: no clear evidence of benefit of POP surgery, prolapse unlikely to progress within 3 years
OVERALL:
-Most studies have shown that significantly more women are continent following concomitant POP and SUI procedures compared with POP repair only.
-Despite concomitant continence surgery, SUI can still persist in approximately one-third of women
-Lower success rate of all secondary continence procedures compared with primary procedures.
-In almost one-third of women, prolapse repair alone can improve SUI symptoms.
-Some studies have shown that, although SUI may persist or develop after POP repair alone, not all women opt for further surgery.
What is Fowler’s syndrome?
Complete urinary retention with characteristic EMG of urinary sphincter spasm
Affects:
women, painless urinary retention of often large volumes (>1000ml), no improvement with straining, association with Endo/PCOS
Very painful catheterisation/removal of catheter “something gripping”
How do you diagnose and treat Fowler’s syndrome?
Investigations:
Urethral pressure profile (>100)
EMG: complex, repetitive discharges generating low level continuous excitation + contraction
Urethral ultrasound to detect sphincter volume (can rule out diverticulum)
Treatment:
Sacroneuromodulation
Botox A injections
Differential diagnosis of Fowler’s syndrome
Structual obstruction - diverticulae, fibroids, strictures, tumours
Neurological - would have associated symptoms such as MSA, spinal cord disease,
Other: meds (opiates), functional
What are risk factors for prolapse?
Parity + large birth weight
BMI
Chronic constipation
Genetic predisposition
What are the limitations of hysterectomy for pelvic organ prolapse?
Vault prolapse - 6x higher in women who had hysterectomy for prolapse over other indications
Affects 5-43% of women
Altered bladder and bowel function - 60% increase in Urinary incontinence
Dyspareunia - 15% increase in rate following anterior repair, higher following posterior
What points of suspension are used when performing laparoscopic suspension of the uterus?
The round ligaments (ventrosuspension);
Uterosacral ligaments (uterosacral plication);
Sacral promontory (hysteropexy).
Describe methods of vault repair
Abdominal more effective than vaginal
Laparoscopic: uterosacral ligament suspension, sacrocolpoplexy
RCOG recommends laparoscopic route for sacrocolpopexy because of its reduced rate of intraoperative bleeding, hospital stay and wound complications.
What are the complications of vaginal mesh?
What rates do they have?
Vaginal mesh exposure occurred in 4.4% of women after retropubic MUS and 2.7% after transobturator MUS.
Mesh erosion into the urethra and bladder is rare, with groin pain and chronic pain reported in 1–9% of procedures.
Complications include mesh exposure, erosion, infection and pain.
What is the NICE recommendation for surgical management of stress incontinence?
Laparoscopic colposuspension has equal outcomes with open and shorter recovery times.
However longer operating times, more technically demanding.
NICE:
NICE recommends
offering midurethral sling, open colposuspension or autologous sling surgery to those who have failed conservative measures to treat stress urinary incontinence.
Confirms equivalence in outcome, concern over surgical competency and potential cost means that NICE does not recommend the laparoscopic route as a routine procedure.
How do anticholinergic drugs work?
Anticholinergic drugs act by blocking muscarinic receptors in the bladder smooth muscle, leading to a direct relaxant effect.
(Bladder is M3 specifically)
Side effects: dry mouth, constipation and dry eyes occur as a result of blockade of these receptors at other sites.
Contraindications: Myasthenia gravis, significant bladder outflow obstruction, severe ulcerative colitis, toxic megacolon and in gastrointestinal obstruction or atony.
What is the MOA of Mirabegron?
Beta-3-adrenoceptor agonist
Acts by enhancing bladder relaxation during the storage phase of micturition.
It has been found to be a safe and effective treatment for OAB, in comparison with placebo and tolterodine tartrate.
Side effects: Tachycardia, UTI
Contraindications: Uncontrolled hypertension
What is the MOA of Botox ?
Botox is a neurotoxin released by Clostridium botulinum.
Acts presynaptically by cleaving synaptosomal-associated protein 25 (SNAP-25), which is required for fusion of neurotransmitter-containing vesicles
Causes decrease of acetylcholine release across the neuromuscular junction and muscle paralysis
The MOA may also include a complex inhibitory effect on vesicular release of excitatory neurotransmitters and the axonal expression of other proteins. These are thought to be important in mediating the intrinsic or spinal reflexes thought to cause neurogenic detrusor overactivity.This suggests that the sensory afferent pathway is involved.
The toxin is resistant to proteolysis and persists in the neurons for a long time, giving a clinical effect of between three and six months
Onabotulinum toxin A is used clinically
Risks of botox treatment for OAB
According to NICE:
The risk of clean intermittent catheterisation and the potential for it to be needed for variable lengths of time after the effect of the injections has worn off
The absence of evidence on duration of effect between treatments and the long-term efficacy and risks
The risk of adverse effects, including an increased risk of urinary tract infection
What are the adverse effects of sacral nerve stimulation?
Reoperation rate of 33% due to pain and infection at the implantation site, or lead migration (causing loss of effect) requiring repositioning.
Wound infections or breakdown, and adverse effects on bowel symptoms.
9% of treated patients needed permanent removal of the electrodes.
What is the definition of recurrent UTI?
At least three UTIs in a year, or two UTIs in 6 months
What are treatment options for recurrent UTI?
Low dose antibiotic prophylaxis - continuous, post-coital, rescue, self-dip and treat
However increasing antibiotic resistance, and side effects on gut/vaginal flora
Chinese herbal medicine - Er Xian Tang more effective than generic but not good evidence
Methenamine - weak inactive base that slowly hydrolyses in urine to form formaldehyde - weak evidence only
Cranberry juice - Cochrane no significant benefit
D-mannose - potentially benefit, NICE state non-pregnant women can try
Lactobacilli - safe, not as good as antibiotics, need more data
Urethral dilatation (at time of cystoscopy) - no improve over cystoscopy alone but 30% patient reported improvement in symptoms
Oestrogens - fall in oestrogen levels post-menopause resulting in reduced lactobacilli
Systematic review - vaginal oestrogen effective in preventing recurrent UTI, systematic not
offer in post-menopausal women
Glycosaminoglycans - most superficial layer of bladder endothelium, repels antibiotic pili from binding
Chronic inflammation linked with deficiency of GAG layer
Replacement with synthetic hyalonuric acid shows promising benefit
Offer in pre-menopausal women 4 x weekly installations then 2 x monthly installations
Sublingual vaccination - designed to create response on submucosal surfaces. It also produces a systemic immunoglobulin G (IgG), immunoglobulin A (IgA) and cytotoxic T-lymphocyte response, resulting in protective immunity
Currently phase 2 trial of vaccine against . coli, Klebsiella pneumoniae, Proteus vulgaris and Enterococcus faecalis.
What is urethral hyper mobility?
Caused by pelvic floor damage during childbirth, with loss of the normal urethral support provided by pubourethral ligaments and the anterior vaginal wall.
Clinically: descent and anterior rotation of the anterior vaginal wall is observed during a cough, in association with urine leakage
What are surgical options for stress Urinary incontinence?
Operations to augment urethral sphincter closure
-Urethral bulking injections
-Artificial sphincters
Operations to suspend the vaginal wall
-Colposuspension (open or laparoscopic)
-Mid-urethral tapes (retropubic or transobturator)
-Autologous slings
Others (no longer recommended)
-Bladder neck needle suspension
Which patient groups are appropriate for urethral bulking agents?
-Patient preference
-Not suitable for surgery (anaesthetic risk)
-Planning to conceive
-Recurrent SUI after failed primary surgery
Which agents are used for urethral bulking injections?
Silicone
Carbon-coated zirconium beads
Hyaluronic acid/dextran copolymer
Polyacrylamide hydrogel (Bulkamid)
-These are permanent materials
-May require more than 1 injection
-Limited evidence on durability
-Limited long term evidence on adverse effects
