Urogynaecology

Question 1

What is the definition of urogenital prolapse?

Answer 1

Descent of urogential organs leading to protrusion on the vaginal walls

Question 2

What are the different types of urogenital prolapse?

Answer 2

Anterior compartment:

• Urethrocele (urethra protruding into lower anterior vaginal wall)
• Cystocele (bladder protruding into upper anterior vaginal wall)

Posterior compartment:
- Rectocele - rectal prolapse into posterior wall of vagina

Middle compartment:

• Uterine prolapse - uterus descends into vagina
• Vaginal vault prolapse -top part of vagina pushing down on lower part
• Enterocele - pouch of Douglas (containing bowel loops) pushing through upper posterior wall

Question 3

Risk factors for urogenital prolapse…

Answer 3

• Vaginal delivery
• Multiparity
• Previous pelvic surgery
• High BMI
• Heavy lifting
• Menopause (loss of collagenous tissue)

Question 4

Baden Walker classification of prolapse…

Answer 4

0 = normal position of all parts
1 = leading surface descends halfway to hymen 
2 = leading surface descends to hymen 
3 = leading surface descends halfway past hymen 
4 = total eversion of vagina (total prolapse)

Question 5

Symptoms of urogenital prolapse…

Answer 5

• Dragging sensation
• May feel palpable lump
• Lower back pain
• Discomfort during sex
• Urinary sx: frequency, urgency, incontinence

Question 6

Management of urogenital prolapse…

Answer 6

Conservative:

• Weight loss
• Physiotherapy course for pelvic floor exercises
• Manage chronic disease

Medical:
Vaginal pessary:
- Ring pessary = most common, can still maintain sex life
- Shell pessary = more severe prolapse, CANNOT be sexually active

Surgical:

• Cystocele/ cystourethrocele = anterior colporrhaphy, colposuspension
• uterine prolapse = hysterectomy, sacrohysterpexy ( uterus and cervix attached to sacrum using mesh)
• rectocele = posteror colporrhaphyy

Question 7

How does a vaginal pessary work?

Answer 7

Pessary acts as an artificial pelvic floor which prevents the descent of pelvic organs.

Question 8

What are the two main causes of urinary incontinence?

Answer 8

• Urge incontinence - overactive bladder where there is involuntary detrusor activity during filling phase
• Stress incontinence - where increase in abdominal pressure leads to rise in bladder pressure due to impaired urethral sphincter

Question 9

Investigations in urinary incontinence…

Answer 9

• Urinalysis - MC&S for infection, glucose for diabetes, haematuria may indicate malignancy
• Bladder diary -record fluid input and output, episodes of incontinence
• Urodynamic studies - cystometry determines bladder pressure. If leakage occurs with increased abdo pressure and absence of detrusor contraction it is stress incontinence, but if detrusor contraction is present it is OAB.
• USS to show if there is incomplete emptying
• CT KUB with contrast to look for blockages

Question 10

Management of stress incontinence…

Answer 10

Conservative:
1st line = 3 month trial of pelvic floor exercises - increasing difficulty

Medical:
1st line = Duloxetine 20-40mg BD - S/Es: dry mouth, nausea, dizziness

Surgical:

• Mid-urethral tape and rectal fascial sling
• Periureteral bulking agents

Question 11

Management of OAB…

Answer 11

Conservative:

• Lifestyle changes : weight loss, reduce caffeine intake, no drinking past 5pm
• Medication review: diuretics
• Bladder training- timed delay of voiding, +ve reinforcement

Medical:

• Anti-cholinergics e.g. oxybutinin - S/Es= dry mouth, retention
• Sympathomimetics e.g. Miragebron -bladder antispasmodic
• Botox - 10-30 injections of detrusor muscle - S/E = retention

Surgical :
- Augmentation cystoplasty (graft used to make bladder bigger)

Other:
- S3 nerve stimulation - alter inhibit innervation of detrusor muscle