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RC OBGYN (CG) > Urogyne > Flashcards

Urogyne Flashcards

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1
Q

Name the 3 types of pessaries

A

Support (Ring, Ring w diaphragm, Shaatz)

Space-occupying (Cube, donut, inflatoball, Gellhorn)

Incontinence (Ring w support and knob, incontinence ring, incontinence dish, Uresta device)

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2
Q

Name the predictors of pessary discontinuation (4)

A

Posterior wall prolapse

Younger age (< 65 yo)

Urinary incontinence

Discomfort

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3
Q

Which anticholinergic medication can be used with cholinesterase inhibitors (for Alzheimer’s disease)

A

Trospium (Trosec)

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4
Q

Name common complications of pessaries (3)

A

Increased discharge (physiologic)

Erosion (2-9 %)

Vaginal infections (2.5%) - BV, yeast

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5
Q

With which medication does Miragebron need a dose adjustment

A

Digoxin

(Also need to monitor digoxin levels more closely)

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6
Q

Name the 2 reasons that justify urologic work-up (cysto and imaging of upper urinary tract) in patients with UTIs

A

1- Infection by organisms not commonly causing UTIs

  • Proteus
  • Pseudomonas
  • Enterobacter
  • Klebsiella

2- Persistent hematuria after resolution of infection

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7
Q

What is the most common complaint of pessaries

A

Vaginal discharge

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8
Q

Which anticholinergic has the best efficacy to reduce norcturnal micturitions

A

Fesoterodine (Toviaz)

In addition:

  • decreases nocturnal urgency episodes
  • Improve subjective sleep quality
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9
Q

How is a UTI defined in terms of CFU (2)

A

1- > 100 000 CFU (10 ^5) /HPF

2- Symptoms of UTI + > 1000 CFU/ HPF

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10
Q

Which OAB medications are slective and non- selective M3 antagonists

A

Non-selective:

  • Oxybutinin (Ditropan)
  • Tolterodine (Detrol)
  • Trospium (Trosec)

Selective: (SDF)

  • Solifenacin (Vesicare)
  • Darifenacin (Enablex)
  • Fesoteridine (Toviaz)
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11
Q

Name the positive predictive factors for recurrent UTIs (5)

A

Symptoms after intercourse

Prior hx of pyelonephritis

Absence of nocturia

Prompt resolution of symptoms (48h) after initiation of treatment

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12
Q

Name common side effects of anticholinergics

A

Dry mouth

Constipation

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13
Q

What is the risk of re-operation for mesh exposure after transvaginal mesh placement

A

4-8%

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14
Q

Name the most common pathogens involved in recurrent UTIs

A
  • E-coli (80%)
  • S. Saprofyticus, Klebsiella pneumoniae, Proteus mirabilus (4%)
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15
Q

What are the presenting symptoms of vaginal mesh exposure (5)

A

Vaginal discharge

Vaginal bleeding

Pain

Dyspareunia

Partner’s discomfort w intercourse

(Often asymptomatic and found on exam)

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16
Q

Name the 2 medications linked to increased QT

A

Tolterodine (Detrol)

Solifenacin (Vesicare)

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17
Q

Which pessaries have the less chance of self care (3)

A

Gellhorn

Cube

Donut

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18
Q

What is a nomal PVR value

What is the % of urine emptied with a normal void

A

PVR: 100- 150 mL

75-80 % of total bladder volume

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19
Q

DDx of UTI (5)

A
  • Chlamydia
  • Gonorrhea
  • HSV
  • Vaginal yeast infection
  • BV
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20
Q

Name the 5 components of urodynamic testing

A

1- Uroflowmetry

2- PVR

3- Bladder function

  • Cystometry
  • Pressure flow study

4- Urethral function tests (urethral pressure profile & abdominal leak point)

5- Electromyography

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21
Q

What is the treatment of a recurrent UTI within the first week post Tx

A

Urine C+S

Fluoroquinolone x 7 days

Norfloxacin, cipro, ofloxacin, fleroxacin

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22
Q

About UTIs which is more common between reinfection or relapse

A

Reinfection

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23
Q

Describe the “spil-over effect” of vaginal estrogens

A

Transcient increase in plasma estrogen levels at initiation of vaginal therapy secondary to decreased vaginal estrogen absorption in highly atrophied tissue. Resolves by 7-14 days max

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24
Q

Name the RFs for recurrent UTIs in pre-menopausal women (4)

A

Initial infection with e-coli

Dysfunctional voiding patterns (increased tone in the external sphincter during micturition)

Hx of UTIs before 15

Maternal hx of UTIs

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25
What are the appropriate regimen for prevention of recurrent UTI in pregnancy (2)
Nitrofurantoin 50 mg Cephalexin 250 mg Either post-coital OR continuous
26
Which parameter of a UA is the most specific?
Nitrites (92-100%) Followed by Leukocyte esterase (41-86%) Blood (42-46%)
27
What is the preferred surgical approach for mesh complications
Vaginal route Abdominal or laparoscopic if vaginal fails
28
Name the 7 medications for OAB
Darifenacin (Enablex) Solifenacin (Vesicare) Fesoterodine (Toviaz) Tolterodine tartrate (Detrol) Trospium chloride (Trosec) Mirabegron (Myrbitriq) Oxybutinin (Ditropan)
29
What are the RF for mesh exposure (2)
Concomitant hysterectomy Smoking
30
31
What are options for management of mesh complications
**Conservative management** - Vaginal estrogen - Pelvic floor physio - NSAIDs, muscle relaxants, neuroleptics **Mesh revision** - Excision of exposed area - Release of contracted/ tender arm of mesh - Partial mesh excision - Complete mesh excision
32
# Define: - UTI relapse - UTI reinfection
**UTI relapse :** - Recurrent infection with the same organism despite adequate therapy **UTI reinfection:** Recurrent UTI cause by: - a different bacterial isolate OR - previously isolated bacteria after (1) a negative culture OR (2) 2 weeks between infections
33
Name native tissue reconstructive techniques POP (4)
Anterior/ posterior colporrhaphy McCall culdoplasty Sacrospinous ligament suspension Uterosacral ligament suspension
34
Mechanism of action of Abx to prevent recurrent UTI
1- Septra and Norfloxacin : decrease the rate of recovery of gram neg pathogens from fecal reservoir 2 - Nitrofurantoin: decreases recurrence by intermittently sterilizing the urine and possibly inhibiting bacterial attachment
35
Should you continue your mesh placement after: 1 - Bladder injury 2 - Rectal injury
**Bladder injury:** Not enough evidence to suggest either way BUT small injuries could potentially be repaired and mesh placed (risk of fistula to be considered) **Rectal injury:** DO NOT place mesh
36
What is the risk (%) of mesh exposure AND surgery in which compartment has the lowest risk of exposure
12 % Anterior compartment
37
Name the predictors of unsuccessful pessary fitting (5)
Short vagina (\< 6 cm) Wide introitus (\> 4 finger breadth) Rectocele Previous vaginal surgery Coexisting SUI
38
Name the relative contraindications to anticholinergics (8)
Borderline or high PVR (Partial bladder outlet obstruction) Controlled narrow-angle glaucoma Impaired cognitive function Reduced renal or hepatic function Concomitant excessive alcohol use (adding sedative effects) Decreased GI motility Constipation Myastenia gravis
39
Name the pessary used for cervical incompetance
Arabin pessary
40
How do you follow a UTI (symptomatic or asymptomatic) in pregnancy?
Test of cure 1 week post completion of therapy Monthly follow-ups until end of pregnancy
41
Which anticholinergics is the safest in the elderly?
Fesoterodine (Toviaz) **Other options:** Tolterodine (Detrol) # 1 Solifenacin (Vesisare) # 2 Darifenacin #2 Trospium #3
42
Name the 5 complications that are increased in vaginal mesh repairs compared to native tissue repairs
Intraoperative bladder injury (increased 4 fold) Bleeding \> 500 mL Post-operative hematoma De novo stress incontinence Non-sexual pain (vaginal, buttock, groin pain)
43
In what circumstances would you use a space occupying pessary in first intention?
Vaginal introitus width \> 3-4 fingers
44
Name treatment options for refractory OAB
Botox (type A) detrusor injections Central neurostimulation Peripheral neurostimulation (sacral or tibial nerve)
45
Which type of vaginal mesh is associated with less complications
Polypropylene type 1 monofilament, macroporous synthetic mesh
46
What is the definition of recurrent UTI
2 uncomplicated UTIs in 6 months or 2-3 uncomplicated UTIs in 1 year
47
Mirabegron should be used with caution in what population
Patients with poorly controlled cardiovascular RF Patients \> 80 yo
48
Which pessaries allow for intercourse (2) and which ones should be removed (3)
Intercourse: Ring, Shaatz Removal: Cube, donut, Gellhorn
49
Name the only life style modification that was shown to decrease recurrent UTIs
DC spermicide/ diaphragm use
50
What are the indications for UTI prophylaxis in pregnancy (3)
Pre-pregnancy hx of recurrent UTI Persistent symptomatic or asymptomatic bacteriuria after 2 abx treatment One UTI and RF for urinary complications (DM, sickle cell trait)
51
Name RFs for UTI in post-menopausal women (6)
Previous UTI Incontinence Pelvic floor prolapse High PVR Diabetes mellitus Non secretors of histocompatibility blood-group AG
52
Mechanism of action of incontinence pessaries
Elevate and slightly constrict the urethra ... which... Stabilize the urethra and increase urethral resistance
53
Describe the changes in the vaginal flora which pre-dispose to UTI in post-menopausal women
Decreased estrogen at menopause → thinning of vaginal epithelium + decrease amount of glycogen. Environement now hostile to lactobacillus (protective as they prevent colonization by e-coli) → decrease # of lactobacillus → increase vaginal pH → increase risk of colinization with uropathogens
54
Name the factors predicting Septra resistance (4)
DM Use of abx in the past 3-6 mo (no matter the reason) Recent hospitalization Recent TMP-SMX use
55
Name alternative measures to reduce recurrent UTIs (3+2)
Cranberries Acupuncture Estrogen in post-menopausal women Probiotics (early evidence) Intravaginal vaccine (ealy evidence)
56
Which anticholinergic can be used with other CYP450 inhibitors
Trospium (Trosec) - Level 3B
57
Name absolute contraindications to anticholinergics (5)
Urinary retention Gastric retention Uncontrolled narrow-angle glaucoma Known hypersensitivity to the drugs
58
How does the vaginal pH change with menopause
Increases (less acidic = more basic)
59
Name the RF for UTIs in pre-menopausal women (3)
Frequent Intercourse Spermicide New sexual partners
60
Treatment of erosion from pessary
Remove pessary x 2-4 weeks Vaginal estrogen (tabs or cream) Change type or size of pessary Biopsy (vaginal cancer) if persistant to r/o vaginal cancer
61
What are the 3 categories of symptoms linked to GUSM
**1 - Urogenital atrophy** * Vaginal dryness * Irritation * Burning * Dyspareunia * Post coital bleeding **2- Lower urinary tract dysfunction** * Recurrent UTIs * Urinary urgency * Urinary frequency * Nocturia * Incontinence * Dysuria **3- Sexual dysfunction** * Lack of lubrication * Discomfort * Pain * Impaired function * Arousal/ desire issues
62
63
Name 2 factors that would suggest an alternate dx then recurrent UTI
- Nocturia - Persistence of symptoms between episodes of treated infection
64
Which anticholinergics are safe to use in cardiac patients (2)
Tolterodine (Detrol) # 1 Darifenacin (Enablex)
65
Treatment of increased physiological discharge with pessaries
Replens Trimo-San cream
66
Name the potential complications of vaginal mesh surgery (8)
Infection Bleeding Organ injury + risk of fistula Prolapse recurrence Mesh exposure Persistent pelvic pain Dyspareunia New incontinence symptoms
67
Name the 3 types of vaginal estrogens
**Premarin cream** 0.625 mg/g (Congugated equine estrogen) **Vagifem tabs** 10 ug (micronized estradiol) **Estring ring** (estradiol)
68
What are the 3 formulas for recurrent UTI treatment and Name 2 options for recurrent UTI prophylaxis
Continuous prophylaxis Post-coital single dose Acute self treament

RC OBGYN (CG) (13 decks)

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