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urogynae Flashcards

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1
Q

What are the main things covered by urogynae?

A

Urinary problems eg. incontinence, voiding disorder, cystitis, UTI, fistulae

Prolapse

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2
Q

What things should you include in a urogynae history?

A 
Urological history
Gynaecological history
Obstetric history
Colorectal history (presence of any bowel Sx)
Medical history
Drug history
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3
Q

What questions should you include in the urological history?

A

Incontinence - onset
stress/urge
volume
frequency

Irritative - frequency
urgency
nocturne
dysuria

Voiding - poor stream, straining, prolonged, incomplete emptying, dribbling after leaving toilet

UTI’s
Nocturnal enuresis
Prolapses
Childhood problems
Catheterisation
Retention
Past treatments
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4
Q

What questions should you include in the gynaecological history?

A 
Menstrual
Prolapse
Surgery
General
Sexual dysfunction
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5
Q

What questions should you include in the obstetric history?

A

parity
MOD
birthweights

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6
Q

What questions should you include in the medical history?

A 
Respiratory (cough)
Cardiac
GI (constipation)
CNS
Diabetes
Psychiatric
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7
Q

What questions should you include in the drug history?

A

Diuretics
Beta-blockers
Anti-cholinergics

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8
Q

What should be included in an urogynae examination?

A

General (BMI important)

Abdominal (pelvic masses)

Digital examination of pelvic floor muscles

Bimanual vaginal examination (to assess fro prolapse)

Speculum:
Post menopausal atrophy
Vaginal discharge
Prolapse

Incontinence

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9
Q

What investigations are commonly done in urogynaecology?

A

Urine dipstick +/- MSU
Frequency/volume charts
Post-voidal residual volume (bladder scan)
Urodynamics

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10
Q

What is urodynamics? How is it done?

A

Assessment of bladder function

Outpatient
Bladder filled and emptied whilst pressure readings taken from bladder and abdo

(Important before any surgical intervention or if initial treatment failed)

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11
Q

What is incontinence?

A

Objectively demonstrable involuntary loss of urine

social or hygienic problem

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12
Q

What are the 4 types of incontinence?

A
  1. STRESS URINARY INCONTINENCE
  2. URGE URINARY INCONTINENCE
  3. MIXED URINARY INCONTINENCE
  4. CONTINUOUS URINARY INCONTINENCE
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13
Q

What is stress urinary incontinence?

A

Involuntary loss of urine on effort or exertion or on
coughing/sneezing etc

Any factor which increases intra-abdominal pressure will cause SUI

Due to an incompetent sphincter.

(Stress incontinence may be associated with genitourinary prolapse)

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14
Q

What is urge urinary incontinence also known as?

A

detrusor overactivity - detrusor instability or hyperreflexia leading to involuntary detrusor contraction

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15
Q

What is urge urinary incontinence?

A

Urgency - strong desire to void

Urge incontinence: involuntary loss of urine preceded by an intense desire to void

nocturnal enuresis

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16
Q

What are common anterior compartment prolapses? What is the most common?

A

Urethrocele (urethra)
Cystocele (bladder)
cystourethrocele

Protrusion of urethra/bladder into vaginal canal

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17
Q

What are common mid compartment prolapses?

A

uterine - uterus into vaginal canal

vaginal vault - vaginal vault post-hysterectomy

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18
Q

What are common posterior compartment prolapses?

A

rectocele (rectum into vagina)

enterocoele (pouch of douglas into vagina)

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19
Q

What is a pelvic organ prolapse? Why does it happen?

A

Protrusion of pelvic organs into (or out of) the vaginal canal

Caused by damage to vagina and its pelvic support system - weakens support structure

(pelvic organs supported by levator ani muscles and endoplasmic fascia)

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20
Q

What are some examples of direct injuries to vagina and pelvic support system? What causes these?

A

Detachments and lacerations of connective tissue or stretching and tearing of elevator ani muscles

eg. muscle trauma
Neuropathic injury
Vaginal delivery (most commonly)

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21
Q

What are some examples of indirect injuries to vagina and pelvic support system?

A

hypoestrogenic atrophy and denervation

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22
Q

What are some non-surgical methods of managing prolapse?

A

reduce weight (BMI <30)

Physiotherapy (pelvic floor exercise)

Pessaries

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23
Q

What are some surgical methods of managing prolapse?

A

Anterior repair (bladder)

Posterior repair

Vaginal hysterectomy

(Use of vaginal mesh)

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24
Q

Which type of incontinence if the most common? What is the second dos common?

A

urodynamic stress incontinence (USI)

Detrusor over-activity (overactive bladder)

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25
What are some risk factors for USI?
Age (menopause) Vaginal delivery Prolapse Previous bladder neck surgery
26
How does USI usually present?
Stress incontinence | can also have concomitant urgency/urge incontinence
27
How is USI diagnosed?
Urodynamics: if urine leaks with no change in pressure in the bladder muscle. Leaking is provoked by an increase in pressure inside the abdomen (eg. when coughing) Urine leak occurs with: Increase in abdo pressure No increase in bladder pressure
28
What are some non-surgical managements of USI?
Conservative: Containment products Physiotherapy/pelvic floor exercises: first-line Reduce weight (BMI <30) Vaginal Cones Second line: Duloxetine (effects on urethra) SE: hesitancy in initiating urination Electrical stimulation Surgical: if conservative measures fail. Retropubic mid-urethral tape Colposuspension Autologous rectal fascial sling
29
What are some surgical managements of USI?
Trans-Vaginal-Tape Burch’s colposuspension Artificial sphincter (Injectables Collagen Macroplastic Teflon)
30
What is the second most common cause of incontinence? What age group is this most associated with?
Detrusor overactivity Older women
31
How does detrusor activity usually present?
``` Irritative symptoms: frequency urgency urge incontinence nocturia dysuria Abdo discomfort ```
32
How is detrusor overactivity diagnosed?
Urodynamics: If involuntary bladder muscle activity causes an increase in pressure in the bladder and leads to leaking. Urine leak with: Involuntary pressure increase in bladder
33
What are the non-surgical management options for detrusor overactivity?
Reduce tea/coffee (alter fluids) Weight loss Stop Smoking Bladder retraining. First line. (min. 6 weeks) Drug therapy: Antimuscarinic - oxybutynin (Tricyclic antidepressants Desmopressin)
34
What are the surgical/secondary care management options for detrusor overactivity?
Intra-Vesical Botox - first line (risk of UTI and self-catheterisation) Sacral Nerve Stimulation - second line Surgery: if intractable/v. severe Clam cystoplasty Neromodulator implant Detrusor myomectomy
35
What are some common causes of detrusor activity/urge incontinence?
idiopathic secondary to neurological problems, eg. stroke, Parkinson's disease, multiple sclerosis, dementia or spinal cord injury Local irritation due to infection or bladder stones.
36
What is mixed urinary incontinence?
involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.
37
What is continuous urinary incontinence?
There is continuous leakage of urine. May be fistulous track between the vagina and the ureter, or bladder, or urethra.
38
What are some risk factors for urinary incontinence?
``` Pregnancy and vaginal delivery (incl. forceps and heavier baby) DM High BMI Peri-menopausal (stress incontinence) hysterectomy ```
39
What is bladder training?
pelvic muscle training scheduled voiding intervals with stepped increase Suppression of urge with distraction or relaxation techniques
40
How does oxybutynin (anti-muscarinic) impact over-active bladder?
Reduced detrusor over-activity Relax urinary smooth muscle Increase bladder capacity
41
Other than urodynamic study, what other investigations should be done for someone with detrusor over-activity?
Bloods: U&Es, creatinine, glucose, calcium urine dip +/- MSU
42
Which patients should be considered for 2 week cancer referral?
Microscopic haematuria >= 50 yrs Macroscopic haematuria Recurrent UTI + haematuria >= 40yrs Suspect malignant match
43
How should mixed urinary incontinence be managed?
Treat predominant symptoms Pelvic floor and bladder training: first line Anti-muscarinics: oxybutynin = second line (or if neurological disease) May need to consider botulin toxin type A injections
44
What are some side effects of anti-muscarinics to warn patients about?
Constipation Urinary retention Confusion
45
What are some symptoms of urethrocele?
stress incontinence
46
What are some symptoms of cystocele?
Often ASx Frequency Recurrent UTI Pressure sensation
47
What are some symptoms of cystourethrocele?
Mixed urinary symptoms eg. stress incontinence, frequency etc.
48
What are some symptoms someone might experience with vaginal vault prolapse?
Urinary retention Sx of ureteric obstruction
49
What are some symptoms someone might experience with enterocoele?
usually ASx (esp. if small) Cough impulse Strangulation rare
50
What are some symptoms someone might experience with rectocele?
Difficulty or pain voiding bowels, dragging sensation May need to self-digitate
51
How is the severity of a prolapse classified?
Based on most distal portion of prolapse during straining
52
What is a stage 0 prolapse?
no prolapse
53
What is a stage 1 prolapse?
>1cm above hymen
54
What is a stage 2 prolapse?
within 1 cm of hymen
55
What is a stage 3 prolapse?
>1cm below hymen but protrudes no further than 2cm less than total length of vagina
56
What is stage 4 prolapse?
complete eversion of the vagina
57
What are some risk factors for prolapse?
``` Age Vaginal delivery Increasing parity Obesity Hx of hysterectomy ```
58
What are some vaginal/general symptoms of prolapse?
Pressure Fullness/heaviness Bulge/protrusion or something coming down Difficulty retaining tampons Spotting (if prolapse or vagina/cervix has ulcerated)
59
What are some urinary symptoms of prolapse?
``` Incontinence Frequency Urgency Feeling of incomplete emptying Weak or prolonged stream May need to change position to pee May need to reduce prolapse to pee ```
60
What are some coital difficulties associated with prolapse?
``` Dyspareunia Loss of vaginal sensation Vaginal flats Loss of arousal Change of body image ```
61
What are some bowel symptoms associated with prolapse?
``` Constipation/straining Urgency of stool Incontinence of flatus or stool Incomplete evacuation Digital pressure on posterior vaginal wall to defecate Digital evacuation ```
62
What examinations should be conducted if suspect a prolapse?
Abdo (masses + tenderness) SIMS speculum in L lateral position Cuscos speculum Rectal examination
63
What investigations should be conducted on someone with prolapse and urinary symptoms?
``` urinalysis MSU Post-voidal residual urine volume Urodynamic Ix (if suspect overactive bladder, prolapse or Hx of surgery) Urea and creatinine Renal US ```
64
What investigations should be conducted on someone with prolapse and bowel symptoms?
Anal manometry Defecography Endo-anal ultrasound
65
What the conservative management options for a prolapse?
Mild or ASx = no treatment Watchful waiting Lifestyle: treat cough, smoking cessation, weight loss, treat constipation Pelvic floor exercises ?oestrogen cream
66
When might conservative management be considered the best course of action?
``` Mild prolapse Pt wants future pregnancies Frail or elderly High anaesthetic risk Pt doesn't want surgery ```
67
When might vaginal pessaries be considered to treat prolapse? How do they work?
Alternative to surgery Short term prior to surgery Insert ring in to vagina: reduces prolapse, provides support and relieved pressure on bladder and bowel Change every 6-12 months Can have intercourse with ring in
68
What complications are associated with vaginal pessaries in prolapse?
Vaginal discharge and odour Vesicovaginal + rectovaginal fistulas Faecal impaction Hydronephritis Urosepsis
69
When might surgery be considered to treat prolapses?
Failure of conservative treatment Presence of voiding symptoms or obstructed defecation Recurrence of prolapse after previous surgery Ulceration Irreducible prolapse Preference of patient
70
What is the aim of surgical treatment? What should patients be warned about?
Aim: to return organs back to normal function May need a number of operations May need re-op in years following procedure
71
What are the surgical options for anterior compartment prolapse?
colporrhaply | colposuspension
72
What are the surgical options for uterine prolapse?
hysterectomy sacrohysteropexy sacrospinous fixation
73
What are the surgical options for vaginal vault prolapse?
Sacropsinous fixation | Sacrocolpopexy
74
What are the surgical options for a rectocele?
colporrhaphy
75
What are the sings of a good prognosis in prolapse? What are the sings of a poor prognosis in prolapse?
young low BMI Good physical health Poor: the opposite of the above
76
What are some complications associated with prolapse?
Ulceration and infection if prolapsed outside introitus Urinary complications Bowel dysfunction

GOSH (33 decks)

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