Urogynae

Question 2

Recall and describe the 5 types of incontinence

Answer 2

Stress - increaed pressure on bladder causes small losses
Urge - string urge and not qiuck enough to loo –> large losses
Mixed - often stress and urge together
Overflow - difficulty emptying –> filling –> incontinence
Functional - due to difficulties in mobility

Question 3

Recall some appropriate investigations for incontinence

Answer 3

1st = speculum - exclude pelvic organ prolapse
- Ask pt to cough during exam (Valsalva) to check for fluid leakage
1st = urine dip (rule out DM or UTI)
1st - bladder diaries (3 days)
If inconclusive:
2nd - urodynamic testing - 3 pressures measured from inside rectum and uretha
Bladder pressure = detrusor + IAP

Question 4

How can stress incontinence be managed?

Answer 4

Check need for referral - trigone tumour needs to be checked
1st line = lifestyle advice and WL and pelvic floor exercises: 8 contractions, TDS, 3 months

2nd line - surgical treatment or SNRI duloxetine (if no surgery wanted)
Surgery = 1. Burch colpo

Question 5

How can urge incontinence be managed?

Answer 5

Check need for referral to specialist as trigone tumour needs to be checked
1st line is conservative: lifestyle advice and bladder training (6 weeks) and avoid fizzy drinks

2nd line = medical: antimuscarinic eg oxybutynin, tolterodine or AD

Question 6

Recall an important side effect of oxybutynin

Answer 6

Increased risk of falls

Question 7

How can overflow incontinence be managed?

Answer 7

Refer to a specialist urogynaecologist - 1st line treatment is timed voiding

Question 8

What should be suspected if there is dribbling incontinence after having a child?

Answer 8

Vesicovaginal fistula: do urinary dye studies

Question 9

What is a uterine prolapse?

Answer 9

Prolapse of uterus into vagina

Question 10

What is a cystocele?

Answer 10

Prolapse anterior vaginal wall involving the bladder

Question 11

What is rectocele?

Answer 11

Prolapse of lower posterior vaginal wall involving the anterior wall of the rectum

Question 12

What is enterocele?

Answer 12

Prolapse of the upper posterior vaginal wall containing loops of small bowel

Question 13

What is a vault prolapse?

Answer 13

Prolapse of vaginal vault after hysterectomy

Question 14

Recall some signs and symptoms of urogenital prolapse

Answer 14

Feelings of heaviness of descent PV
Back pain + dyspareunia
Recurrent UTI
Urinary symptoms is cystocele/ constipation or incontinence if rectocele

Question 15

What is the NICE recommended grading system for urogenital prolapse? Describe it.

Answer 15

POP-Q
Position given as a coordinate relative to the pelvic organs

Question 16

What is the most frequently-used grading system for urogenital prolapse? Describe it.

Answer 16

Shaw’s
1st degree: descent to the introitus
2nd degree: extends to the introitus but descent past the introitus on straining
3rd degree: prolapse descends through the introitus

Question 17

Recall the step-wise managemet of urogenital prolapse

Answer 17

1st line is conservative: WL, minimise weightlifting, stop smoking

2nd line:
- Pelvic floor exercies
- Topical oestrogen in older patients
- Pessary: Ring (doesn’t prevent sex), shelf (common, hard, prevents sex), gellhorn (like shelf but soft, also prevents sex). If more severe - Gehrung or cube (which uses suction to keep things in place)

3rd line - surgical options:

Uterine prolapse: depends on whether there is desire to preserve uterus
To preserve uterus:
- Vaginal sacrospinous hysteropexy with sutures
- Manchester repair, unless the woman may wish to have children in the future
- Sacro-hysteropexy with mesh (abdominal or laparoscopic)
Doesn’t preserve uterus:
- Vaginal hysterectomy, Manchester repair, VSH with sutures

Vault prolapse: Sacrolpopexy with mesh

Anterior/ posterior colporrhaphy without mesh for anterior/ posterior prolapses