Urogynaecology

Question 1

see urogynae notes

Answer 1

anatomy

Question 2

How common is stress incontinence?

Answer 2

50% of incontinence in females

Question 3

What are the causes of stress incontinence?

Answer 3

pregnancy and vaginal delivery esp prolonged labour and forceps delivery 
obesity 
age (esp postmenopausal) 
prolapse 
previous hysterectomy

Question 4

What are the characteristic of stress incontinence?

Answer 4

involuntary leakage of urine on effort or exertion, on sneezing or coughing
many patients also complain of frequency, urgency or urge incontinence
faecal incontinence may also be present
may have cystocoele or urethrocoele

Question 5

How common is urge incontinence?

Answer 5

35% of the cases of female incontinence

Question 6

What are the causes of urge incontinence?

Answer 6

idiopathic
bladder neck obstruction
detrusor overactivity

Question 7

What are the characteristics of urge incontinence?

Answer 7

urgency 
frequency and nocturne 
stress incontinence common 
leak at night or at orgasm 
history of childhood enuresis common as well as faecal urgency

Question 8

What are the causes of urinary frequency?

Answer 8

high fluid intake 
caffeine and alcohol 
infections, UTIs and STIs
Prostate glad problems 
diuretics 
DM
DI 
pregnancy

Question 9

What are the characteristics of urinary frequency?

Answer 9

Urinating more than 8 times a day
nosturia
bladder discomfort
strong urgent need to urinate

Question 10

How common are UTIs in women?

Answer 10

1 in 3 women have had a UTI by the age of 24

Question 11

What are the RFs for developing a UTI?

Answer 11

female 
children 
elderly 
indwelling catheters 
immunosuppression 
urinary tract abnormalities 
antibiotic exposure

Question 12

What are the characteristics of a UTI?

Answer 12

strong persistent urge to urinate 
burning sensation when urinating 
frequent small amounts of urine 
cloudy strong smelling urine 
blood in urine 
pelvic pain

Question 13

What is prolapse?

Answer 13

descent of uterus and/or vaginal walls beyond normal anatomical confines
result of weakness in supporting structures
herniation of bladder/urethra/rectum/small bowels
v common, present in most older porous women

Question 14

What is a urethrocoele?

Answer 14

urethra prolapse only

Question 15

What is a cystocoele?

Answer 15

bladder prolapse

Question 16

What is an apical prolapse?

Answer 16

uterus, cervix and upper vagina prolapse

Question 17

What is an enterocoele?

Answer 17

prolapse contains loops of small bowel

Question 18

What is a rectocoele?

Answer 18

anterior wall of the rectum prolapse

Question 19

What are the causes of prolapse?

Answer 19

vaginal delivery and pregnancy - mechanical injuries and denervation of the pelvic floor
congenital factors
menopause - deterioration of collagen due to lower oestrogen
chronic predisposing factors - obesity/chronic cough/constipation/heavy lifting/pelvic mass
Iatrogenic factors - hysterectomy and continence procedures

Question 20

What are the characteristics of prolapse?

Answer 20

dragging sensation/sensation of the lump
worse at end of the day and when standing
can interfere with intercourse/ulcerate/discharge
urinary frequency/incomplete bladder emptying with cystourethrocele
can have difficulty defecating if rectocele

Question 21

What are the indications for urodynamics investigation?

Answer 21

investigate symptoms of urinary incontinence

prior to surgery for stress incontinence/overactive bladder

Question 22

What are the methods of assessing urodynamics?

Answer 22

catheter measures vesicle pressure (pressure in bladder) whilst bladder is filled and provoked with coughing

pressure transducer also on rectum (or vagina) to measure abdominal pressure

true detrusor pressure = vesicle pressure - abdominal pressure

Question 23

for urodynamics interpretation

Answer 23

see notes

Question 24

What are the indications for cystoscopy?

Answer 24

exclude tumours, stones, fistulae and interstitial cystitis

Question 25

What are the method for cystoscopy?

Answer 25

inspection of the bladder cavity using cystoscope inserted into urethra into bladder

Question 26

What are the indications for imaging (US and IV urography)?

Answer 26

evaluate or detect blood in urine, kidney or bladder stones or cancer in urinary tract

Question 27

What are the method of imaging the urinary tract?

Answer 27

IV urogram – IV contrast injected + X ray to look at kidneys, ureters, bladder + urethra US – soundwaves to create image

Question 28

What coping advice can you give to women for coping with incontinence and retention?

Answer 28

``` reduce excessive fluid intake avoid caffeinated products review medication if obese - lose weight reduce cause of chronic cough ```

Question 29

What pads and garments can be given?

Answer 29

pad and pull ups are temporary measures bed and chair protection with washable bed pads specially adapted clothing and swimwear

Question 30

What types of catheterisation can be used?

Answer 30

clean intermittent catheterisation - used to empty bladder at regular intervals indwelling catheter

Question 31

What are the steps of bladder training?

Answer 31

1 - education 2 - timed voiding with systematic delay in voiding 3 - positive reinforcement 4 - at least 6 weeks

Question 32

What pelvic floor advice can be given?

Answer 32

Strengthing pelvic floor First line treatment for 3+ months, taught by PT >8 contractions, 3x/day Poss use vaginal ‘cones’ or sponges – held in place in vagina by voluntary muscle contraction

Question 33

How can duloxetine be used?

Answer 33

treatment of moderate severe stress incontinence SNRI that enhances urethral striated sphincter activity

Question 34

How can antimuscarinics be used?

Answer 34

suppress detrusor overactivity in bladder overactivity

Question 35

How can oestrogens be used?

Answer 35

in postmenopausal women | improves symptoms of vaginal atrophy and reduces symptoms of urge incontinence

Question 36

How can botulinum toxin A be used?

Answer 36

blocks neuromuscular transmission | duration average 6 months

Question 37

When is a vaginal repair +/- hysterectomy indicated?

Answer 37

recommended for incontinence caused by anterior vaginal wall prolapse bladder and urethra lifted back into place and secure with stitches mesh may be part of repair

Question 38

How is tension-free vaginal tape used?

Answer 38

tape placed in U-shape under mid urethra via small | vaginal anterior wall incision, tension adjusted to prevent leakage as woman coughs

Question 39

How is a trans-obturator tape used?

Answer 39

tape passed via transobturator foramen, through transobturator + puborectalis

Question 40

What are the advantages of sling/tape procedures?

Answer 40

cure rates of up to 90%, minimally invasive

Question 41

What is colposuspension?

Answer 41

Incision on lower abdomen + stitching neck of bladder in lifted position

Question 42

What are the cons of colposuspension?

Answer 42

Can cause urinary retention, recurrent UTIs and discomfort during sex

Question 43

What are the non-surgical treatment options for incontinence?

Answer 43

``` pads and garments catheterisation bladder retraining pelvic floor exercises drug treatment ```

Question 44

What are the surgical treatment options for incontinence?

Answer 44

vaginal repair with or without hysterectomy sing procedure and tapes colposuspension

Question 45

What are the investigations for incontinence?

Answer 45

urodynamics cystoscopy imaging including US and IV urography

Question 46

What is the easiest investigation for urinary infection?

Answer 46

microbiology Ix | Dipstick