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Flashcards in Urogynae Deck (41)
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1

Key features of a urogynae history

Bladder symptoms - Incontinence - Nocturia - Haematuria - Voiding dysfunction

Bowel

POP

Quality of life

Sexual function

Treatment trial to date

2

Stage of POP 

3

POP-Q

4

Examination

Abdominal exam 

Vaginal exam- POP-Q at maximal 

5

Investigations 

 MSU

 

 Bladder diary

 

 Ultrasound

  - adnexal pathology

  - ET

  - Cervical length

Urodynamics

6

Indications for urodynamics

Unclear diagnosis

Invasive surgical interventions are being considered, as choice of procedure is influenced by urodynamic results

Coexisting pathologies to determine which should be treated first, such as obstruction and detrusor overactivity or stress incontinence and detrusor overactivity

Complex problems such as recurrent incontinence, neurological pathology, previous lower urinary tract surgery, pelvic surgery or pelvic radiation.

7

Pressure measures in urodynamic studies

Intravesical pressure (pves) is the pressure within the bladder and is measured by the bladder catheter. It is the sum of the pressure generated by the bladder (detrusor pressure pdet) and the intra-abdominal pressure (pabd).

Abdominal pressure (pabd) is measured by the rectal catheter.

Detrusor pressure (pdet) is the pressure generated by the bladder muscle. In ‘subtraction’ urodynamics (the commonest type) it is calculated electronically using the equation: pdet = pves – pabd.

8

Explain the phases of urodynamic studies

1. The filling phase: assesses bladder sensation and presence of detrusor overactivity (an involuntary contraction of the detrusor muscle) as well as bladder compliance (the ability of the bladder to store urine at low pressures).

2. The voiding phase uses pressure-flow measurements to assess detrusor function and identify obstruction. Pressure flow nomograms can be used and a high pressure/low flow voiding pattern indicates obstruction. Urine flow rate is measured in mL/sec by a urine flowmeter

9

How is bladder sensation assessed?

Bladder sensation is assessed by recording the volume at which the patient experiences:

  • the first sensation of bladder fullness
  • the first desire to void,
  • a  strong desire to void and urgency.

10

What is leak point pressure?

Lowest bladder pressure (pves) that causes urine leakage with a rise in intra-abdominal pressure. Estimated by valsalva or cough. 

Measure of urethral sphincter weakness.

 

A lower leak point pressure indicates worse urethral function.

11

What is uroflowmetry? 

Measures the flow of urine (fastest flow is Qmax):

How fast, how much, and how long it takes. 

 

A slow/low flow rate may mean there is an obstruction at the bladder neck or in the urethra, or a weak bladder.

A fast or high flow rate may mean there are weak muscles around the urethra, or urinary incontinence problems.

12

Filling cystometry, normal result

 

13

Describe this picture: 

Unprovoked rises in detrusor activity

Sensation to void and urgency 

suggestive of detrusor overactivity 

14

Approach to urodynamics

15

Explain the parasympathetic innervation of the bladder

  • Muscarinic receptor
  • Acetylcholine
  • Detrusor muscle contracts
  • Trigone and internal sphincter- relaxes and internal sphincter opens 
  • Therefore causes voiding of bladder

16

Explain the sympathetic innervation of the bladder 

  • Detrusor:
    • Beta receptor
    • Noradrenaline
    • Increased cAMP
    • Relaxes
  • Trigone and internal sphincter
    • Alpha 1 receptor
    • Norad
    • Increased IP3 and DAG 
    • Contraction and internal sphincter closes
  • Urinary retention 

17

Diagram of sympathetic and PNS innervation of bladder

18

Overactive bladder management 

  • Lifestyle/conservative
    • Reduce caffeine
    • Avoid bladder irritants
    • Advise re fluid intake
    • Change of medication e.g diuretics 
    • Bladder training with timed voiding 
    • Bladder diary with education alone can be curative
  • Medical 
    • Anticholinergics e.g. oxybutinin (contraindicated in narrow angle glaucoma, SE: dry mouth, blurred vision, constipation) or vesicare/solifenacin 2nd line and better tolerated
    • TCA e.g. imipramine 
    • Desmopressin 
  • Surgical 
    • Botox 
    • Sacral nerve route stimulation

19

Stress incontinence management 

Conservative 

  • Weight loss
  • Stop smoking
  • Avoid heavy weights and constipation 
  • Treat chronic cough 
  • Reduce fluid intake and avoid triggers

Medical 

  • Pelvic floor strengthening 
  • Consider catheterisation/toileting aides/absorbant pads 
  • Treat atrophy with ovestin 
  • Duloxetine 40mg BD 

Surgical 

  • Support bladder neck 
    • TVT (effect in 80-90%) 
    • Burch colposuspension
  • Augment urethral closure 
    • Urethral bulking agents
    • Artificial urinary sphincter 

20

Conservative management of pelvic organ prolapse

  • Pelvic floor exercises 
  • Weight loss
  • Stop smoking/chronic cough 
  • Vaginal oestrogen
  • Pessary 
    • Se's: irritation/erosions, vesicovaginal fistula

21

Surgical management of POP 

  • Counselling: effect on bladder function, bowels and risk of recurrence 
  • Apical support needed 
    • Vault 
      • LSC + repair preferred 1st option vs either sacrospinous colpopexy or uterosacral colpopexy 
    • Uterine 
      • Decide whether to perform hysterectomy + sacrocolpopexy vs hysteropexy (need to assess for risk factors for malignancy) 
  • Anterior or posterior support needed 
    • Ant or post repair 

22

23

Risk factors for POP

  • Multiparity 
  • Vaginal birth 
  • Forceps delivery
  • Constipation
  • Chronic cough 
  • Neuropathy e.g. spina bifida 
  • Lifestyle- straining/lifting eg. heavy weights
  • Obesity
  • Smoking
  • Menopause
  • Prior surgery 
  • Connective tissue disorders e.g. Marfan's/Ehlos Danlos 
  • Genetics 

24

Pathogenesis of POP 

  • Damage to levator ani
  • Decreased muscle tone and strength, atrophy 
  • Widened levator hiatus
  • Unopposed intra-abdominal pressure on tissues 
  • Connective tissue stretches over time
  • POP

25

Describe 3 levels of Delancey's level of support for pelvic organs 

  • Level I
    • Cardino-uterosacral complex
    • Upper vagina, cervix, LUS
  • Level II
    • Paravaginal supports of bladder
    • Upper 2/3 vagina
    • Rectum
  • Level III
    • Ievator hiatus, urogenital Triangle and anal angle - Lower 1/3 vagina, urethra, anal canal

26

Describe the POP-Q measurement sites

27

Evaluate pros and cons of pessaries

Consider for:

  • Temporary symptomatic relief
  • medically unfit or not wanting surgery
  • may prevent progression –No Level 1 evidence
  • can be used in pregnancy

Best to teach insertion and removal to patient

Use topical estrogen

Review within 2-4 weeks then 4-6 monthly

Cons:

  • 50% discontinuation within first month of fitting
  • Discharge ◦ Infection ◦ Erosions ◦ Ulcerations ◦ Fistula

28

What are the aims of surgical management for POP? 

  • Relieve symptoms
  • Restore anatomy
  • Improve visceral function
  • Improve sexual function
  • Lifetime risk for prolapse surgery 11%
  • Increased to 16% if hysterectomy

29

What is the surgical management for POP of anterior compartment? And specific risks? 

Defects can be lateral (Paravaginal) or central

Depends on detachment of Pubocervical fascia

Central defects – Anterior colporrhaphy

Reattaching the PCF in midline:

  • Failure rates 30% in 5 years
  • Complications:
    • direct injury to bladder > urethra > ureter
    • Indirect via haematoma or denervation
    • Voiding difficulty
    • Vaginal narrowing, sexual dysfunction

Paravaginal defects: detachment of the fascia from the Arcus tendineus fascia pelvis (ATFP)

If levator and PCF detachment: anterior colporrhaphy will fail.

Surgical correction is via abdominal paravaginal repair in retropubic space 

Vaginal mesh repair

30

What is the surgical management for POP of posterior compartment? 

  • Posterior vaginal repair: Rectovaginal fascia plicated in midline
  • Levator ani plication ◦ Aggressive plication gives transverse ridge, narrowing and dyspareunia
  • Perineorrhaphy ◦ Only required if gaping genital hiatus ◦ Reattach the posterior vaginal plication to the perineal body
  • No role for mesh – Level 1 data shows no benefit to recurrance rates and increased dysparuenia
  • 10% 5 year failure rates