Urogynae

Question 1

Which organism is the most common cause of UTIs

Answer 1

Escherichia coli

Question 2

List organisms commonly causing UTIs

Answer 2

Ecoli

Gram neg :
Klebsiela pneumonia
Pseudomonas
Enterobacter spp
Proteus spp

Gram positive:
Enterococcus
Group B strep

In immunocompromised :
Candida
Viruses: adenovirus, cmv

Question 3

List the predisposing factors for UTIs (5)

Answer 3

Female
Pregnancy
Elderly
DM
Immunocompromised: HIV, malnutrition, cancer

Question 4

List the complications of acute pyelonephritis (4)

Answer 4

Septicaemia and septic shock
Abscess (intrarenal or perinephric)
Chronic pyelonephritis
Renal failure

Question 5

List the 4 types of urinary incontinence

Answer 5

1. Overactive bladder syndrome
   -uncontrolled involuntary detrusor muscle contractions during filling that a pt can’t suppress
2. Genuine stress incontinence
   -involuntary loss of urine during physical exertion or straining
3. Overflow incontinence
   -involuntarily loss of urine due to bladder being full. In the absence of detrusor contraction or increase in abdominal pressure
4. True incontinence
   -urinary leakage. Urine is lost via any other route other than the urethra ei urinary fistula or ectopic ureter

Question 6

Outline the classifications of overactive bladder (2)

Answer 6

Unstable detrusor: no disturbance in CNS

Detrusor hyperreflexia: there is a disturbance in CNS causing overactive bladder

Question 7

Which type of urinary incontinence is most common in elderly women

Answer 7

Detrusor overactivity

Question 8

List the symptoms of detrusor overactivity

Answer 8

Frequency
Nocturia
Urgency
Urgency incontinence
Nocturnal enuresis
Incontinence during coitus

Question 9

List the differential diagnosis for detrusor overactivity (4)

Answer 9

Carcinoma of bladder
UTI
Radiation damage to bladder (radiation cystitis)
Bladder stones

Question 10

Discuss the management of detrusor overactivity

Answer 10

Lifestyle changes and physiotherapist
-Reduce fluid intake esp in evening
-Avoid caffeine and alcohol
-Weight loss
-If on diuretics, advise taking them in the morning
-Bladder drill- pt taught to increase interval between voiding in half hour increments. Initially beginning with hourly bladder emptying

Pharmacological
1. Anticholinergic agents:
-Oxybutynin 2.5mg bd up to 5mg tds (Ditropan)
Lyrinel once a day slow release is available (better side effects)
-Tolterodine (Detrusitol) / Solufenicin (Vesicare)
2. Antimuscurinic agents show selectivity for blade over salivary glands decreasing side effects
3. TCAs
a)Imipramine or ethipramine
-useful in nocturia, enuresis&urgency.
-has anticholinergic, anti adrenergic effects and inhibits uptake of noradrenalin and serotonin.
b) Betmiga (mirabegron)
Enhances urinary storage by stimulating beta adrenoceptors increasing mean voided volume and decreasing frequency

Surgical:
Invasive botulinum toxin injection into detrusor muscle (prevents release of acetylcholine)
Neuromodulation
Clam cystoplasty (increasing size of bladder)
Ileal conduit (urine diverted from bladder to reservoir in ileum ie stroma bag)

Question 11

List the side effects of anticholinergic agents in managing incontinence(4)

Answer 11

Dry mouth
Dry eyes
Constipation
Drowsiness

Question 12

What is the contraindication for anticholinergic drugs

Answer 12

Closed angie glaucoma

Question 13

Outline the classification of stress incontinence

Answer 13

Urethral hyper mobility : Urethra and bladder neck are mobile
Intrinsic sphincter defect : internal sphincter defective, urethra and bladder in correct anatomical position

Question 14

List some of the causes of intrinsic sphincter defect (3)

Answer 14

Prev surgery in periurethral area
Pelvic radiotherapy
Idiopathic

Question 15

List some of the causes of urethral hyper mobility (3)

Answer 15

Childbirth
Menopause
Weakened pelvic support (elderly)

Question 16

Discuss the management of stress incontinence

Answer 16

Lifestyle
-Fluid intake 1:5-2l a day
-reduce exacerbating factors eg cough, constipation
-Weight loss
-pelvic floor exercises
-intravaginal insertion of weighted cones
-Vaginal foam tampons

Surgical:
Tension free vaginal tape *gold standard
-placed under midurethra
Burch colposuspension
Pubovaginal sling/ Fascial sling

Urethral bulking agents if unfit for surgery

Question 17

What are the advantages of tension free vagina tape (4)

Answer 17

Minimally invasive
Minimal perioperative morbidity
Short hospital stay
High long term continence rate (>80% at 17 yrs)

Question 18

What is the aetiology of overflow incontinence (overdistended bladder)

Answer 18

Decreased bladder sensation from:
-DM
-Spinal cord lesions

Bladder outlet obstruction
-strictures
Prev surgery

Question 19

List the symptoms of overflow incontinence (4)

Answer 19

Intermittent wetness
Repeated UTIs
Symptoms of voiding dysfunction

Ongoing leaking or dribbling urine
Feeling of bladder fullness even after urinating
Urine stream that stops and restarts during urination
Difficulty urinating even while feeling urge it utinate

Question 20

List the causes of urinary leakage / True incontinence

Answer 20

Iatrogenic:
-following bladder or ureteric injury at hysterectomy
-poor obstetrics practice
-radiotherapy for cervical carcinoma