urogynaecology

Question 1

if you have failure of the pelvic floor at level 1 what type of prolapse is it?

Answer 1

utero-cervical or vault prolapse bc of cervical incompetence

Question 2

what is a cystocele?

Answer 2

anterior vaginal wall prolapse/ bladder prolapse into the vagina

Question 3

what do we mean by ‘apical descent’ prolapse?

Answer 3

uterine/vault prolapse

Question 4

what is a rectocoele?

Answer 4

posterior vaginal wall prolapse/ rectal prolapse into the vagina

Question 5

what is the difference between rectocoele and rectal prolapse?

Answer 5

rectocoele= refers to prolapse through the vagina

rectal prolapse= refers to prolapse through the anus

Question 6

in what setting can a prolapse be life threatening?

Answer 6

If the prolapse is outside for a long time–> infection and sepsis

if there is obstructive uropathy–> urinary retention–> renal failure

Question 7

If a woman has sudden onset prolapse, what do we think of?

Answer 7

a solid tumour causing prolapse

Question 8

what are some causes of nulliparous prolapse?

Answer 8

Collagen tissue disorders like Marfans can cause weakness of endopelvic fascia and so these patients can have prolapse without having children

Spina bifida–> another cause of nulliparous prolapse

Question 9

why are women who have had children and are subsequently heavy lifting in the gym are at high risk of prolapse?

Answer 9

heavy lifting- massive amount of pressure on the abdominal muscles and the levator ani muscles are NOT contracted –> risk of prolapse! So need to do pelvic floor exercises first before attending the gym

Question 10

why might obese women be at risk of pelvic organ prolapse?

Answer 10

sheer weight on the abdomen –> endopelvic fascial trauma

Endopelvic fascia may also be infiltrated with fat –> causing weakened fascia

Question 11

why are diabetic women at risk of pelvic organ prolapse?

Answer 11

poor tissue quality causing weakened endopelvic fascia

Question 12

what are some contributing factors for pelvic organ prolapse?

Answer 12

multiparity, previous surgery, age and decreasing E2 levels

connective tissue disease and denervation conditions

increased intra-abdominal pressure such as obesity etc

Question 13

what are some exacerbating factors for pelvic organ prolapse?

Answer 13

chronic cough, chronic constipation, menopause (endopelvic fascia needs oestrogen and hence becomes weakened during menopause)

Question 14

what are some ways a woman can present with pelvic organ prolapse?

Answer 14

• Dragging pain, lump/bulge

• Bladder or bowel symptoms E.g. stress incontinence
• Or incomplete voiding + recurrent UTIs
• Or complete urinary obstruction if prolapse is massive –> urinary retention

Incomplete/obstructive defecation–> requires digitate vagina to allow defecation
• Faecal incontinence

Difficulty with sexual intercourse

Back ache

Question 15

how might we grade the severity of pelvic organ prolapse?

Answer 15

Baden Walker Classification

0= no prolapse
1= descent halfway to hymen
2= descent to hymen
3= descent halfway PAST the hymen
4= maximal

Question 16

what normally occurs at the levator ani muscles when there is increased intraabdominal pressure?

Answer 16

levator ani muscles contract reducing genital hiatus diameter, preventing pelvic organ prolapse

Question 17

what are some clinical features of urge incontinence?

Answer 17

bladder empties > 8 times per day
bladder empties > 2 times overnight
associated with sense of urgency

Question 18

Why do we always ask whether a patient who has urinary incontinence also has narrow angle glaucoma?

Answer 18

bc the treatment for overactive bladder is anticholinergics which can exacerbate closed angle glaucoma

Question 19

what type of stress incontinence wont respond to kegel exercises?

Answer 19

will not work in stress incontinence due to intrinsic urethral sphincter deficiency

Question 20

what exactly is detrusor overactivity?

Answer 20

involuntary detrusor contractions during the filling phase of the bladder

Question 21

what do we see during urodynamics which confirms stress incontinence?

Answer 21

involuntary leakage of urine during increased abdominal pressure (e.g. cough) in the absence of a detrusor contraction

Question 22

what are some ways we can manage pelvic organ prolapse?

Answer 22

1. conservative management e.g. pelvic floor exercises, weight loss and avoiding lifting heavy objects
2. Vaginal pessary rings
3. Surgery

Question 23

how might we examine pelvic floor prolapses?

Answer 23

If a pelvic organ prolapse is present, the examiner should ascertain what is prolapsing (e.g. bladder [cystocele] or bowel [enterocele]) and the degree of descent.

This is accomplished by using a Sims’ speculum and placing it inside the vagina to support either the anterior or posterior wall during the Valsalva manoeuvre.

Finally, a bimanual examination must be performed to evaluate the prolapse, determine uterine size and position, and identify the presence of pelvic masses

Question 24

what does procidentia refer to in urogynaecology?

Answer 24

failure of genital supports and complete uterine prolapse through the vagina

Question 25

what is the difference between uterine prolapse and vault prolapse?

Answer 25

uterine prolapse= protrusion of uterus and cervix into the vagina

vault prolapse= protrusion of apex of vaginal vault into vagina, post hysterectomy

Question 26

what are important examination things to do for urinary incontinence?

Answer 26

1. assess cognition
2. assess mobility and gait
3. neurological examination- back/lower limbs/perianal sensation etc
4. abdominal examination- abdominal masses
5. pelvic examination- cough impulse, bimanual, pelvic floor strength

Question 27

what ix should we do for a woman presenting with urinary incontinence?

Answer 27

MSU looking for UTI or haematuria
post voidal residual volume using bladder scanner
bladder diary
QOL questionaires

refer for urodynamic studies

Question 28

what type of urinary incontinence are pelvic floor exercises useful?

Answer 28

stress incontinence

overactive bladder

Question 29

what are some general behavioural advice we can give for women with urinary incontinence?

Answer 29

restrict ETOH, caffeine intake or overall fluid intake
reduce fluid intake before bedtime
empty bladder before bed
zinc creams if atrophic vaginitis present
manage constipation if present

Question 30

what medications can we offer a woman with OAB urinary incontinence? (for detruser overactivity)

Answer 30

anticholinergics like oxybutynin
mirabegron- b3 adrenoreceptor agonist

botox IM injection into detruser muscles

Question 31

what is the gold standard surgery for stress urinary incontinence?

Answer 31

mid-urethral sling

Question 32

what are some key questions you should ask on history of a woman with urinary incontinence?

Answer 32

ask about lower urinary tract symptoms

• dysuria, fever, haematuria, frequency, nocturia, urgency
• incontinence with coughing/sneezing
• volume of leak
• typical fluid intake
• sense of dragging sensation or bulge in vagina
• constipation
• dyspareunia, dryness of vagina
• Impact on QOL
• obstetric hx including parity, mode of delivery
• previous surgery e.g. mid urethral sling for incontinence or spinal surgery
• any trauma to back, neurological disease, diabetes
• ask about medications like diuretics/ace inhibitors
• ask about smoking and alcohol

Question 33

what are some key examinations/assessments we should perform for a lady presenting with urinary incontinence?

Answer 33

Assess her cognition/mobility
Perform abdominal exam looking for scars and masses
Pelvic examination 
Cough stress test
Bimanual examination for masses
Pelvic floor muscle contraction
Lower limb neuro exam

Question 34

what is the first ix we should order for urinary incontinence?

Answer 34

MSU to rule out UTI or haematuria

Question 35

what speculum do we use to assess pelvic organ prolapse?

Answer 35

sims speculum- support either side of the vagina to see which wal; (anterior/posterior) is prolapsing