Urogynaecology

Question 1

What is prolapse?

Answer 1

Protrusion of an organ or structure beyond its normal anatomical confines. Female POP refers to the descent of the pelvic organs towards or through the vagina

Question 2

Describe the pathophysiology of POP

Answer 2

Prolapse occurs due to progressive weakness of pelvic floor muscles and stretching of endopelvic fascia/ligaments, which usually supports viscera, so organs fall out of place

Question 3

What is a urethrocele?

Answer 3

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 4

What is a cystocele?

Answer 4

Prolapse of the upper anterior vaginal wall involving the bladder

Question 5

What is a uterovaginal prolapse?

Answer 5

This term is used to describe prolapse of the uterus, cervix and upper vagina

Question 6

What is a enterocele?

Answer 6

Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel

Question 7

What is a rectocele?

Answer 7

Prolapse of the lower posterior wall of the vagina involving the rectum bulging towards into the vagina

Question 8

Give risk factors for POP

Answer 8

Pregnancy and vaginal birth

• Forceps
• Large baby
• Prolonged secondary stage
• Parity

Advancing age:Muscles and ligaments weaken

Obesity: Increased pressure on pelvic floor

Previous pelvic surgery: Heals with fibrous tissue which is weaker

Hormonal/Menopause

Quality of connective tissue

Constipation

Occupation with heavy lifting

Exercise

Anything that involves pushing on ligaments/endoplasmic fascia and muscles

Question 9

Give vaginal symptoms of POP

Answer 9

Sensation of a bulge/protrusion

Seeing or feeling a bulge or protrusion

Pressure

Heaviness

Difficulty in inserting tampons

Difficulty in having sex

Question 10

Give urinary symptoms of POP

Answer 10

Urinary incontinence

Frequency

Urgency

Weak or prolonged urinary stream

Manual reduction of prolapse to start or complete voiding

Question 11

Give bowel symptoms of POP

Answer 11

Incontinence of flatus, liquid or solid stool

Feeling of incomplete emptying/straining

Urgency

Digital evacuation to complete defecation

Splinting or pushing on or around the vagina to start or complete defecation

Question 12

What investigations can be used in POP diagnosis?

Answer 12

USS/MRI: Allow identification of fascial defects/measurement of levator ani thickness

Urodynamics: Concurrent urinary incontinence

IVU or renal USS: If suspect ureteric obstruction

Only do investigations if think there is associated conditions

Question 13

What non surgical management is available for POP?

Answer 13

Pelvic floor muscle training: Mild prolapse, increase pelvic strength and bulk and relieve the tension on the ligaments

Perinometer: Measures strength of voluntary contractions

Biofeedback: Monitors if doing contraction right

Vaginal cones

Electrical stimulation: Helps patient find muscle and contract if weak

Pessaries: Late stage, just as good as surgery

Question 14

What is surgery used for in POP?

Answer 14

Maintains vaginal capacity for sexual function

Restore/maintains bladder and bowel function

Relieves symptoms

Question 15

What preventative measures are used in POP?

Answer 15

Avoid constipation

Effective management chronic chest pathology

Smaller family size

Improvements in antenatal and intra-partum care

Question 16

What is urgency?

Answer 16

The complaint of a sudden, compelling desire to pass urine that is difficult to defer

Question 17

What is urge incontinence?

Answer 17

The complaint of involuntary leakage of urine accompanied or immediately preceded by urgency

Question 18

What is frequency?

Answer 18

Usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids too often by day

Question 19

What is nocturia?

Answer 19

Usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void

Question 20

What is stress incontinence?

Answer 20

Leakage accompanying physical activity such as coughing, sneezing, heavy lifting, running, laughing etc

Question 21

Describe Oxford grade 0 of pelvic floor muscles

Answer 21

No muscle activity

Question 22

Describe Oxford grade 1 of pelvic floor muscles

Answer 22

Minor muscle activity

Question 23

Describe Oxford grade 2 of pelvic floor muscles

Answer 23

Weak muscle activity without circular contraction

Question 24

Describe Oxford grade 3 of pelvic floor muscles

Answer 24

Moderate muscle contraction

Question 25

Describe Oxford grade 4 of pelvic floor muscles

Answer 25

Good muscle contraction

Question 26

Describe Oxford grade 5 of pelvic floor muscles

Answer 26

Strong muscle contraction

Question 27

Give risk factors for incontinence

Answer 27

\>Age: increasingly fibrotic bladder \>Parity Menopause Smoking Medical problems Obesity: Increased intraabdominal pressure Pelvic floor trauma Denervation Connective tissue disease Surgery

Question 28

How does incontinence present?

Answer 28

Irritation syndrome * Urgency * Increased daytime frequency (\>7) * Nocturia (\>1) * Dysuria * Haematuria Incontinence Voiding symptoms * Straining to void * Interrupted flow Prolapse Bowel * Anal incontinence * Constipation * Faecal evacuation * Dysfunction * IBS

Question 29

What investigations are used in incontinence diagnosis?

Answer 29

Urine dipsticka and culture, to rule out UTI and diabetes 3 day urinary diary Post voiding residual volume assessment * Usually by bladder scanning, only if voiding difficulty symptoms Urodynamics, only indicated if surgical treatment is contemplated

Question 30

What is noted in the 3 day urinary diary?

Answer 30

Fluid intake Urine out put excluding nocturnal polyuria Daytime frequency Nocturia Average voided volume

Question 31

What lifestyle changes are used in incontinence management?

Answer 31

Stop smoking Lose weight Eat healthy to avoid constipation Stop drinking alcohol, caffeine, chocolate

Question 32

What non surgical methods are used in incontinence management?

Answer 32

Pelvic Floor Muscle Training: Reinforcement of cortical awareness of muscle groups Yentreve (Duloxetine): Should be part of an overall management strategy that should include pelvic floor muscle training

Question 33

How often are pelvic floor muscle exercises done?

Answer 33

3 sets 5 x a day

Question 34

When is duloxetine used?

Answer 34

Use if pelvic floor muscle training has failed or would be enhanced in primary care Use if not fit for surgery, failed surgery in secondary care

Question 35

Give adverse effects of duloxetine

Answer 35

Nausea Mood change

Question 36

Give the procedural/surgical methods used in incontinence management

Answer 36

Colposuspension/Surgery Tension-free Vaginal Tape (TVT): Reinforces structures supporting the urethra

Question 37

What is overactive bladder syndrome?

Answer 37

Symptom complex usually related to urodynamically demonstrable detrusor overactivity

Question 38

Give risk factors for overactive bladder syndrome

Answer 38

Advanced age Diabetes Urinary tract infections Smoking

Question 39

What lifetsyle interventions are used in overactive bladder syndrome?

Answer 39

Normalise fluid intake, Reduce caffeine/fizzy drinks/chocolate Stop smoking Weight los

Question 40

What non pharmacological method is used in overactive bladder syndrome management?

Answer 40

Bladder training programme: Timed voiding with gradually increasing intervals

Question 41

Give the pharmacological methods of overactive bladder syndrome management

Answer 41

Antimuscarinic/anticholinergic Betmiga/Muscle relaxant Tri-cyclic antidepressants used for nocturia Botox: Injected into bladder to relax bladder/reduce contractions and reduce sensory pathway Neuromodulation

Question 42

What is first line medical management for stress incontinence?

Answer 42

Duloxetine, after adequate trial of pelvic floor training

Question 43

What is first line medical management of urge incontinence?

Answer 43

Mucurinic antagonist, after trial of bladder retraining