Urogynaecology Flashcards
(67 cards)
1
Q
What is urinary incontinence?
A
- the loss of control of urination
- it can be divided into stress incontinence & urge incontinence
- it is possible to have a mixed picture
2
Q
What causes urge incontinence?
A
caused by overactivity of the detrusor muscle of the bladder
also called “overactive bladder”
the detrusor muscle contracts before the bladder is full
3
Q
What is the typical presentation of urge incontinence?
A
- a sudden urge to pass urine
- there is a sudden need to rush to the bathroom and often not making it in time
this has a significant impact on QoL with many women avoiding work / activities where there is not easy access to a toilet
4
Q
What causes stress incontinence?
A
- caused by weakness of the pelvic floor and sphincter muscles
- the urethral, vaginal and rectal canals become lax when they are poorly supported by the pelvic floor muscles
5
Q
What is the typical presentation of stress incontinence?
A
- there is leakage when laughing, coughing, exercising or when surprised
- this is due to an increased pressure on the bladder
6
Q
If someone presents with mixed incontinence, what is it important to establish?
A
- it is important to identify which type of incontinence is having the most significant impact
- this will be the primary focus of treatment
7
Q
What is overflow incontinence and why does it occur?
A
- occurs in chronic urinary retention due to an obstruction to the outflow of urine
- chronic urinary retention results in an overflow of urine and incontinence WITHOUT the urge to pass urine
this is more common in males and rare in females
8
Q
What medications / conditions are associated with overflow incontinence?
A
- anticholinergic medications
- fibroids
- pelvic tumours
- neurological conditions - MS, diabetic neuropathy, spinal cord lesions
9
Q
What are the risk factors for urinary incontinence?
A
- increased age
- high BMI
- postmenopausal status
- previous pregnancies + vaginal deliveries
- pelvic floor surgery
- pelvic organ prolapse
- neurological conditions / cognitive impairment / dementia
10
Q
What is the most important element of history taking in incontinence?
A
- establish whether it is stress or urge incontinence
- is there leakage when coughing / lauging
- is there a sudden urge to pass urine with a loss of control on the way to the toilet
11
Q
What questions are asked in a history to establish the severity of incontinence?
A
- frequency of urination AND incontinence
- presence of nocturia
- use of pads / changing of clothes
- dysuria
- haematuria
- difficulty initiating urination / incomplete emptying
12
Q
What gynae/obs questions need to be asked during an incontinence history?
A
- presence of a uterus
- pre- or post-menopausal
- pain / incontinence during intercourse
- previous pregnancies and delivery method including type of forceps used
- smear tests - are they up to date?
13
Q
What type of forceps are associated with an increased risk of incontinence?
A
Kielland forceps
- these are used when rotation of the fetal head is required
- the rotary motion can disturb the pelvic floor muscles and result in stress incontinence
14
Q
Why is it important to establish menopausal status in incontinence?
A
- vaginal atrophy can occur after the menopause
- this causes urinary frequency + recurrent UTIs
- the vaginal cells become more flaccid in the absence of oestrogen
replacing the oestrogen can often sort the symptoms
15
Q
What other symptoms / medical conditions should be asked about in an incontinence history?
A
- presence of prolapse symptoms
- constipation
- chronic cough (can worsen stress incontinence)
- diabetes + how well controlled it is
polyuria can occur in poorly controlled diabetes
16
Q
What questions are important to ask during a medication history in urinary incontinence?
A
- are they taking diuretics
- are they taking laxatives
- have they already tried medication for their urinary symptoms? - what was it? did it help? any side effects?
diuretic may be able to be discontinued or the dose changed
17
Q
What questions need to be asked in the social history in urinary incontinence?
A
- caffeine consumption
- alcohol consumption
- use of ketamine
- smoking
- carbonated drinks
- occupation - is heavy lifting involved? does the environment contain dust / chemicals?
caffeine is found in tea (incl. green tea), chocolate, pro plus, energy drinks + coffee
18
Q
What is involved in the physical examination in incontinence?
A
examination assesses the pelvic tone and examines for:
- atrophic vaginitis
- pelvic organ prolapse
- pelvic masses
- urethral diverticulum
- the patient is asked to cough to observe for leakage from the urethra
abdominal and vaginal examinations are performed
19
Q
What investigation should be performed in all cases of incontinence?
A
urine dipstick +/- MSU
- this examines for microscopic haematuria
- if present, urine dip is repeated in 2 weeks
- if still present, patient is referred via 2WW pathway
- also can detect presence of chronic / recurrent UTIs
20
Q
Why is it important to calculate BMI in incontinence?
A
- surgery is NOT performed unless BMI < 30
- there is an 80% chance of failure if BMI is > 30
21
Q
How can the strength of the pelvic floor muscles be assessed?
A
bimanual examination
- ask the woman to squeeze against the examining fingers
- the modified Oxford grading system can be used to grade strength of pelvic muscle contractions
22
Q
What is involved in the modified Oxford grading system?
A
- 0 - no contraction
- 1 - faint contraction
- 2 - weak contraction
- 3 - moderate contraction with some resistance
- 4 - good contraction with resistance
- 5 - strong contraction - firm squeeze + drawing inwards
23
Q
What is involved in the modified Oxford grading system?
A
- 0 - no contraction
- 1 - faint contraction
- 2 - weak contraction
- 3 - moderate contraction with some resistance
- 4 - good contraction with resistance
- 5 - strong contraction - firm squeeze + drawing inwards
stage 1 can also be described as a “flicker” of contraction
24
Q
What are the first 2 stages in the management of incontinence (of either kind)?
A
lifestyle changes:
- reduce caffiene / fizzy drinks / smoking / alcohol
- weight loss
physiotherapy:
- pelvic floor exercises
- this involves 8 contractions 3 times a day for 3 months
25
Following physiotherapy, what other interventions may be offered in urge incontinence?
**bladder diary:**
* tracks fluid intake + urination + episodes of incontinence
* should be tracked over at least 3 days
* days should be a mixture of work and leisure days
**bladder drills**
26
After initial interventions for incontinence management are implemented, what is done?
* **follow up in 3 months**
* this assesses whether lifestyle changes / physiotherapy has improved symptoms
* further intervention may be required
27
What test should anyone presenting with stress incontinence have?
**urodynamic test**
* can determine whether stress or urge incontinence is present
* 1 in 10 presentations of stress incontinence are actually urge
28
What is involved in urodynamic testing?
* a **thin catheter** is inserted into the **bladder** and into the **rectum**
* the catheters measure the **pressure** in the bladder / rectum
* the bladder is **filled with fluid**
* stress incontinence is present if the **bladder pressure + rectal pressure rise equally**, there is no influence from the detrusor muscle contracting
29
How do stress and urge incontinence appear on urodynamic testing?
**stress incontinence:**
* there is a ***matching rise*** in bladder pressure and **abdominal** (rectal) **pressure**
* there is no activity of the detrusor muscle
**urge incontinence:**
* there is an increase in ***bladder pressure*** + ***detrusor muscle activity***
* there is no change in abdominal pressure
30
What is the leak point pressure on urodynamics and how is it measured?
* the point at which the **bladder pressure** results in **leakage of urine**
* the patient is asked to **cough / move / jump** when the bladder is filled to various capacities
* this assesses for **stress incontinence**
31
What is involved in the management of stress incontinence?
* a trial of **duloxetine**
* if this is unsuccessful, **surgery** is considered
* **pelvic floor exercises** must be performed for **at least 3 months** before surgery is considered
32
What are the surgical options for stress incontinence?
**autologous sling procedures:**
* a strip of fascia is used to support the urethra
**colposuspension:**
* involves pulling the vaginal wall forward to increase support to the urethra
**intramural urethral bulking:**
* injections around the urethra to reduce diameter + add support
33
What is the first line treatment for urge incontinence?
**bladder retraining**
* this involves gradually **increasing the time between voiding**
* it should be performed for **at least 6 weeks** before other treatment is considered
34
What are the first line medications for urge incontinence?
**anticholinergics:**
* ***oxybutynin*** and ***tolterodine*** are usually used
* ***solfencanin*** is sometimes used
**vaginal oestrogens:**
* given to post-menopausal women who have ***vaginal atrophy***
35
What is an alternative medication to anticholinergics in urge incontinence?
mirabegron
| (beta-3 agonist)
36
What are the side effects associated with anticholinergic medications?
* dry mouth / eyes
* urinary retention
* constipation
* postural hypotension
* can lead to **cognitive decline, memory problems + worsening of dementia**
* **use with CAUTION in elderly patients**
37
What are the contraindications to mirabegron?
**uncontrolled hypertension**
* blood pressure must be **monitored** during treatment
* mirabegron **raises the BP**, which can lead to a **hypertensive crisis**
* and increased risk of **TIA / stroke**
38
What is done if urge incontinence does not respond to anticholinergic medication?
* a **second anticholinergic** is trialled
* if this fails, invasive interventions are considered
39
What are the invasive options for treating urge incontinence?
**botulinum toxin type A:**
* a botox injection into the bladder wall
* repeated every 6 months
**percutaneous sacral nerve stimulation:**
* a device implanted in the back stimulates the sacral nerves
**augmentation cystoplasty:**
* bowel tissue is used to enlarge the bladder
**urinary diversion:**
* urinary flow is redirected to a urostomy
39
What are the invasive options for treating urge incontinence?
**botulinum toxin type A:**
* a botox injection into the bladder wall
* repeated every 6 months
**percutaneous sacral nerve stimulation:**
* a device implanted in the back stimulates the sacral nerves
**augmentation cystoplasty:**
* bowel tissue is used to enlarge the bladder
**urinary diversion:**
* urinary flow is redirected to a urostomy
40
What is pelvic organ prolapse?
* the **descent of pelvic organs** into the *vagina*
* occurs due to **weakness + lengthening** of the ligaments and muscles surrounding the **uterus**, **rectum** and **bladder**
41
What are the 4 main types of prolapse?
* uterine prolapse
* rectocele
* cystocele
* vault prolapse
42
What is a uterine prolapse?
the uterus descends into the vagina
43
What is a vault prolapse?
* occurs in women who have had a **hysterectomy** and **do not have a uterus**
* the **top of the vagina (vault)** descends into the vagina
44
What is a rectocele?
* there is a defect in the **posterior vaginal wall**
* this allows the **rectum** to prolapse forwards into the vagina
45
What is the most prominent symptom of rectocele?
* **faecal loading** can occur in the prolapsed part of the rectum
* this causes **significant constipation**
* there is **urinary retention** as the urethra is compressed
46
How might a rectocele present?
* there may be a **palpable lump in the vagina**
* women may use their fingers to push the lump backwards, correcting the anatomical position and allowing them to open their bowels
47
What is a cystocele?
* there is a defect in the **anterior abdominal wall**
* the **bladder** prolapses backwards into the vagina
* prolapse of the urethra is possible (urethrocele)
* prolapse of the bladder + urethra is a cystourethrocele
48
What are the risk factors for pelvic organ prolapse?
* multiple vaginal deliveries
* instrumental, traumatic or prolonged delivery
* advanced age
* postmenopausal status
* obesity
* chronic coughing
* chronic constipation
## Footnote
the risk factors are all related to weak and stretched muscles / ligaments in the pelvic floor
49
What is the presentation of a pelvic organ prolapse?
* a **dragging / heavy sensation** in the pelvis
* a feeling of **"something coming down"** in the vagina
* **urinary symptoms** - frequency, urgency, retention, weak stream
* **bowel symptoms** - constipation, urgency, incontinence
* **sexual dysfunction** - pain, altered sensation
50
What do women often come presenting with in a prolapse?
* a **lump / mass in the vagina**
* they will sometimes be pushing back up themselves
* it gets worse on **straining** or **bearing down**
51
What should be done prior to examination of a prolapse?
ensure the patient has emptied their bladder + bowel
52
What position should the patient be in for examination of a prolapse?
* various positions are often attempted
* this includes the **dorsal** and **left lateral** positions
53
What is involved in a prolapse examination?
**Sim's speculum**
* a U-shaped speculum used to **support the anterior or posterior vaginal wall** while the other walls are examined
* the woman is asked to **cough / bear down** to assess full descent of the prolapse
## Footnote
* Sim's speculum held on **anterior wall** to assess for **rectocele**
* and it is held on the posterior wall to assess for **cystocele**
54
How is the severity of prolapse graded?
Baden-Walker system
55
What are the different grades in the Baden Walker system?
**normal:**
* normal position for each respective site
**first degree:**
* descent halfway to the hymen
**second degree:**
* descent to the hymen
**third degree:**
* descent halfway past the hymen
**procidentia:**
* maximum possible descent
56
What is uterine procidentia?
a prolapse extending beyond the introitus of the vagina
57
What are the 3 treatment options for prolapse?
1. conservative management
2. pessary
3. surgery
58
When might conservative management for prolapse be chosen?
* women who can cope with **mild symptoms**
* they may not tolerate pessaries
* and not be suitable for surgery
59
What is involved in conservative management for prolapse?
* **physiotherapy** + pelvic floor exercises
* **weight loss**
* **vaginal oestrogen cream**
* lifestyle changes + treatment of symptoms if there is associated incontinence
60
How do vaginal pessaries treat prolapse?
* they are inserted into the vagina to **provide extra support** to the pelvic organs
* they are **removed + replaced regularly** (usually every 4 months)
61
How is it decided which type of pessary should be used?
* women often **try a few types** of pessary before finding the correct comfort / symptom relief
* the **ring pessary** allows for **sexual intercourse** without removal
* the **cube pessary** tends to be used by **younger women** as it is **taken out every night** and during sex
62
What should always be given alongside a pessary and why?
**vaginal oestrogen cream**
* this helps to protect the vaginal walls from **irritation**
* pessaries can cause irritation and erosion over time
63
When might surgery be considered for pelvic organ prolapse?
* this may be an **anterior / posterior repair** or **hysterectomy**
* the benefits are balanced against the risks
* e.g. wanting more children in the future, presence of comorbidities
64
What are the potential complications of pelvic organ prolapse surgery?
* **recurrence** of the prolapse
* **altered experience** of sex
* damage to the **bladder / bowel**
* pain, bleeding, infection, risk of DVT
* risk of anaesthetic
65
What are mesh repairs and what is significant about them?
* a **plastic mesh** is inserted to support the pelvic organs
* can be used to treat prolapse / incontinence
* they are **no longer performed** due to the risks, but **complications from previous procedures** may present
66
What are the complications associated with mesh repairs?
* **chronic pain**
* **altered sensation**
* abnormal **bleeding**
* urinary / bowel problems
* **dyspareunia** (painful sex) for the woman / her partner
