Urogynaecology Flashcards
What are the three types of incontinence?
Stress
Urge
Mixed
What things should you ask in an incontinence history?
How often are they going in the day?
How often are they going in the night (more than once per night abnormal for most)/
Do they notice leaking urine when they run/jump/laugh/cough/sneeze?
When they need the toilet do they have to go right then or can they wait?
Have they every had an accidents?
What sort of impact is it having on their life?
How many children have they had? - What sort of deliveries?
Pre or post menopausal
Are the bowels okay (constipation can have knock on effect)?
Prev Gynae hx?
Prev smear hx?
Prev infections hx?
Prolapse - dragging sensation or feeling of fullness?
INFECTION SIGNS: dysuria, changes in appearance, smell, blood in urine. lower abdomen pain
PMH: diabetes
DH: diuretics
LIFESTYLE: caffeine, alcohol, carbonated drinks, smoking, illicit drugs
What should an examination of a woman with incontinence involve?
BMI
Urine dip
Abdo exam (masses)
Cough while on couch (urine leak/prolapse)
Speculum - looking for vaginal atrophy and evidence of fibroids
Smear if appropriate
What lifestyles factors can we recommend to women with EITHER stress or urge incontinence?
Reduce smoking, reduce alcohol, reduce caffeinated drinks, loose weight
After lifestyle factors what can we recommend to women with either urge or stress incontinence?
PELVIC FLOOR TRAINING
- Women should be referred to physiotherapist and they should be recommended to be doing at least 8 contractions at least 3 times a day for 3 months
After physiotherapy what is the next step of management for urge incontinence?
Ask women to keep a BLADDER DIARY and do bladder drills (try and hold wee for 5 minutes longer etc.)
After bladder diaries and bladder drills what is the next stage of management for urge incontinence?
Anticholinergic medications and/or vaginal oestrogen
1st - oxybutynin or tolteridone
2nd line - Trospium or mirabegnon (technically is a B-3 receptor which helps to relax detrusor muscle)
After this can try CYTSOSCOPY AND BOTOX - botox injections around detrusor muscle 100U under LA - ideally we do 10 but women can often only tolerate 3-4, Will usually last 9-11 months then repeated - RISK OF DETRUSOR PARALYSIS - self catheterise
Sacral nerve stimulation via the tibial nerve - 30min treatments every 12w
After physiotherapy what further treatment can be offered for stress incontinence?
Not a lot…
Can give duloxetine after discussion at MDT
Bulkamid injections around neck of bladder also useful
How should mixed incontinence be treated?
Should ALWAYS treat the urge first - risk of making urge worse if you treat stress first
What should you do to confirm the type of incontinence if the picture is more confusing?
Do urodynamic studies
How will women with prolapses present?
Heavy dragging sensation or may even describe feeling something 'coming down' Usually not pain just uncomfortable lower back ache Pain on intercourse Might have noticed a lump
What factors should you cover in the hx of a woman with prolapse?
how long has it been there for? Has it changed? Any pain? Anything make it better or worse? Any changes in sexual function
Ask about previous gynaecological history
Ask about previous obstetric hx
What are the two possible positions of prolapses?
ANTERIOR PROLAPSE - aka cystocele - bladder pushing through anterior vaginal wall
POSTERIOR PROLAPSE - Rectocele or enterocoele
Might also see cervical prolapse, vault prolapse (after hysterectomy)
How are prolapses graded?
Depending on their descent relative to the hymen
How can we managed prolapses?
LIFESTYLE - weight loss, avoid heavy lifting and lifestyle factors
PESSARIES - small rings placed into vagina to hold everything up (can have sex with doughnut ones but not Gellhorn ones)
SURGICAL REPAIR - if pessaries not tolerated. Risk of recurrence is 1/3
