1
Q
What are the three categories of LUTS symptoms?
A
storage, voiding and post micturition
2
Q
What is stress incontinence defined as?
A
involuntary leakage of urine on effort or exertion, sneezing or coughing
3
Q
What is urge incontinence defined as?
A
involuntary leakage accompanied by or immediately preceded by urgency
4
Q
What is included on storage symptoms in LUTS?
A
stresss, urge and mixed incontinence
urgency, increased frequency and nocturia
5
Q
What are included in voiding symptoms?
A
straining
terminal dribble
slow stream
intermittent stream
hesitancy
6
Q
What are post micturition symptoms?
A
incomplete emptying sensation
post micturition dribble
7
Q
What is the prevalence of UI?
A
13-35%
8
Q
When is the highest prevlance of UI?
A
60s
9
Q
What is the most common type of UI?
A
stress
10
Q
What is overactive bladder?
A
urgency +/- urge incontinence usually with nocturia and frequency in the absence of UTI or other pathology
11
Q
what proportion of OAB have stress incontinence also?
A
1/3
12
Q
What are the risk factors for UI?
A
smoking
age
BMI
parity forceps > NVD > CS
hysterectomy
menopause
13
Q
Why is smoking a risk factor for UI?
A
coughing and collagen reduction
14
Q
How do we know estrogen receptors in the LUT effect continence?
A
urodynamics change in the menstrual cycle
rise in LUTS >70y
improves with ovestin
15
Q
How many layers of muscle are there of the bladder wall, what are they?
A
3
inner and outer are longitudinal
middle, circular oblique
16
Q
What is the nerve involved in bladder filling? what receptors and neuro chemical is used
A
detrusor relaxation
sympathetic relaxation by the hypogastric nerve
T10-L2
adrenaline/NA
Beta 3 receptors
17
Q
What nerve is involved in bladder voiding? what receptors and neuro chemical is used
A
Detrusor contraction
parasympathetic
pelvic splanchnic nerves
S2-4
acetyl choline
M3 receptors
18
Q
What is the embryological origin of the bladder trigone?
A
the mesonephric ducts eg wolffian ducts
19
Q
What receptors are found in the bladder trigone?
A
noradrenergic
20
Q
What receptors are found in the bladder (apart from the trigone)?
A
cholinergic receptors
21
Q
Where does the urethra pass from and to?
A
the bladder neck to the external urethral meatus
22
Q
What are the three layers of the urethra?
A
inner - mucosal and submucosal
middle - smooth muscle
outer - striated muscle
23
Q
What is the external urethral sphincter made up of?
A
spans 60% of the urethra length, made of circular striated muscle
24
Q
What controls the EUS?
A
pudendal nerve - tonically contracted
25
what makes up the internal urethral sphincter?
detrusor muscle fibres, smooth muscle
26
What nerve controls the IUS?
sympathetic control, hypogastric nerve
27
In addition to the urinary sphincters what else contributes to urinary continence in women?
dense vasculature around the urethra in the submucosa (atrophy in menopause)
28
what are the two structural causes of SUI?
increased urethral mobility
intrinsic sphincter deficiency
29
how does increased urethral mobility contribute to SUI?
Loss of sub-urethral support of the endopelvic fascia leading to increased urethral mobility with coughing, stress
usually the fascia supports the urethra and allows it to compress and maintain continence. as the support weakness the urethra moves inferiorly with stress rather than compresses
30
what does intrinsic sphincter deficiency mean in SUI?
weakness of the sphincter complex due to defective function of the striated and smooth muscle and mucosal and submucosal cushions
31
What makes up the micturition cycle?
filing and voiding phases
32
How does the filling phase of micturition occur?
detrusor relaxed via the hypogastric nerve (T10-L2) and contraction of the sphincters
33
How does the voiding phase of micturition occur?
detrusor contracts via the pelvic splanchnic nerve S2-4 and the urethral relaxes pudendal nerve S2-3 and pelvic floor relaxes
34
What reflex in the brain coordinates micturition?
pontine micturition centre
35
what are the two causes to rule out in OAB?
neurological disease and obstruction eg post surgery
36
what neurological causes can cause neurological detrusor overactivity?
cerebrovascular disease, parkinsons, tumour, dementia, MS
37
In a history of UI what other pathology should be considered?
UTI
fistula
retention
POP
neurogenic
diabetes
38
What position should you examine POP Q in?
lithotomy but can also stand
39
What is involved in a vaginal exam for UI?
signs of estrogen deficiency, irritation, dermatoses
anterior wall - urethral meatus, urethral diverticulum, cysts
cough impulse
bimanual - adnexal masses, cervical descent, uterine size
POP Q
consider PR
40
what is an abnormal PVR on bladder scan?
>100ml
41
How many days is a bladder diary over?
at least 3 days
42
what four parameters does a bladder diary assess?
number and volume of voids
leakage episodes
Urgency symptoms
intake volume and type
43
What is abnormal for number of voids on a bladder diary?
>8 per day or >1 per night
44
what is a normal fluid intake per day?
1-5/2L
45
What would be a positive pad test?
5g differene
46
What is the questionnaires used to assess UI?
King's Health Questionnaire
incontinence quality of life scale I-QOL
47
What is the aim of urodynamics?
To diagnose pathology causing LUTS to guide surgical management and and predict problems that may follow interventions
48
what would a slow flow rate on urodynamics predictive of after continence surgery?
voiding difficulty
49
what would detrusor overactivity on urodynamics predictive of after continence surgery?
worsening OAB
50
What tests are involved in urodynamics?
uroflowmetry
cystometry - filling and voiding
urethral pressure profile
leak point pressure
PVR
Pressure voiding studies
51
what is uroflowmetry measured in and the measurement called?
Qmax
ml/s
52
What is normal Qmax measurment?
15-25ml/s
53
how is cystometry set up?
a catheter in the bladder for filling
a catheter in the bladder for pressure measurement
a catheter in the rectum to measure abdominal pressure
54
What is done during cystometry and what is measured?
the bladder is filled at 50ml/min
reproduce symptoms - running a tap, cough
urodynamic traces
first desire to void
strong desire to void
maximum capacity
voiding cystometry - pressure and flow rate
55
What is the urodynamic definition of detrusor overactivity?
Involuntary detrusor contractions during the filling phase which may be spontaneous or provoked
56
What is the urodynamic definition of stress incontinence?
Involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
57
what can a small maximum capacity mean on urodynamics?
interstitial cystitis
detrusor overactivity
58
What investigations are considered in urinary incontinence?
voiding diary
PVR
urine dip
pad test
QOL questionnaire
urodynamics
cystoscopy - only if atypical symptoms
59
what are the causes of LUTS?
* Stress incontinence
* Overactive bladder/detrusor overactivity
* Overflow incontinence
* Fistulae
* Urethral diverticulum
* Congenital anomalies
* Functional incontinence (e.g. immobility)
* Temporary incontinence, e.g. due to constipation or UTI
60
what is the difference between OAB and detrusor overactivity?
OAB is the symptoms complex - urgency, nocturia, frequency in the absence of other pathology
detrusor overactivity is a urodynamic observation
61
what advice for you give for OAB on fluid intake?
aim 1-1.5L/day
avoid coffee, fizzy, tea, ETOH
avoid fluid 2-3 hours before bed
62
What medications should be stopped if possible in OAB?
diuretics, CCBs, doxasocin
63
What general management is advised in OAB?
fluid management
weight loss BMI <30
pelvic floor exercises
review meds
estrogen cream
64
What conservative interventions are there for OAB?
bladder retraining
biofeedback - behavioural therapy with sensor feedback
acupuncture
65
How do you do bladder retaining?
PU every 1.5 hours, extend by .5 hours as able
keep a fluid balance chart
66
which antimuscarinic has a more favourable SE profile?
solifenacin
67
What ate the risks in older patients of solifenacin?
sedation, confusion, dizziness, falls, worsening CAD, CHF, HTN, tachycardia
68
What are the side effects of antimuscarinincs?
dry mouth, constipation, blurred vision, urinary retention, nausea
69
What is mirabegron?
for OAB, beta-3 adrenoreceptor agonist
causes relaxation and inhibition of contractions
70
Who needs caution with starting merabegron?
HTN patient
71
can you use merabegron and solifenacin together?
yes
72
What are options for refractory OAB?
botox
neuromodulation
reconstructive surgery
73
How does botox work?
blocks acetyl choline release from the presynaptic nerve terminal at the motor end plate
74
What are the adverse effects of bladder botocx?
voiding difficulties, need for self cath, UTI
75
how long can you get improvement from bladder botox?
3.5 years
76
what is PTNS?
percutaneous tibial nerve stimulation
77
What nerve roots are involved in tibial nerve?
L4-S3 - same nerve roots as the innervation to the pelvic floor and bladder
78
How successful if PTNS for OAB?
70% get >50% improvement,
46% cured
79
what is more effective PTNS or meds for OAB?
same
80
How often do you have to have PTNS done?
weekly for 12 weeks then 3-4 weekly indefinitely
81
How does sacral nerve root stimulation work for OAB?
permanent implantable device sacral nerves contain the autonomic bladder nerves and pelvic floor nerves
pelvic floor nerve are easiest to stimulate as largest
82
What reconstructive surgery is possible for OAB?
clam cystoplasty - gut inserted
Detrusor myectomy - bladder diverticulum
aim to increased capacity of the bladder
83
What conservative options are there for SUI management?
weight loss
PFE
electrical stimulation
vaginal devices - pessary
duloxetine - not first or 2nd line
84
How much weight loss is needed for 47% reduction in SUI?
8%
85
How long should you do PFE for in SUI for 1st line treatment?
3/12
86
how many PFE per day are recommended in SUI?
8, 3 times per day
87
what is duloxetine? common side effect?
SNRI, increases sphincter tone, nausea
88
What is involved in an colposuspension?
peri urethral and paravaginal tissue at the levels of the urethrovesical junction sutured to the cooper's ligament
89
What is another name of the cooper's liagment?
the pectineal ligament
90
What are the risks of a colposuspension?
voiding difficulties
urgency - may have been masked pre op
exacerbation of posterior compartment prolapse
91
What is the cure rate of fascial slings?
70% 48-94%
92
What are the complications of fascial sling?
bladder injury, wound infection, de novo detrusor overactivity, retention, POP, UTI, dyspareunia, suprapubic pain
93
What is bulkamid made of?
polyacrylamide hydrogel
94
where is bulkamid injected?
submucosal tissues of bladder neck or urethra
95
In mixed UI what should you focus on?
the worst symptoms
96
What % of urge symptoms improve with a mid urethral sling?
50-60%
97
If acute urinary retention of >1000ml how long should you re catheterise for?
1 week
98
What imaging can be used to confirm a bladder fistula?
cystoscopy, IVU
99
What is the management of vesicovaginal fistula if not noted intraop?
usually treated conservatively -> bladder drainage + antibiotics, if spontaneous closure doesn't occur then surgical closure
100
What is the IUGA definition of POP?
falling, slipping or downward displacement of the uterus and/or the different vaginal compartments and their neighboring organs such as bladder, rectum or bowel
101
What is the lifetime risk of undergoing POP surgery?
11-19%
102
on exam what is the prevalence of POP?
31-40%
103
What % of women report POP?
9%
104
What are risk factors of POP?
age
parity
mode of delivery
connective tissue disorder
family Hx
ethnicity
obesity
COPD/smoking
constipation
occupation - heavy lifting
estrogen def
105
What three muscles are in the levator anii?
iliococcygeus
puborectalis
pubococcygeus
106
What nerve level innervates the levator anii?
S3-4
107
where do the levator anii originate from?
pubic bone, the white line and ischial spines
108
where do the levator anii insert?
urethra, perineal body, lower part of coccyx, anococcygeal raphe
109
what is the urogential diaphragm?
a triangular sheet of dense fibrous tissue spanning the anterior half of the pelvic outlet
110
what is the urogenital diaphragm also called?
perineal membrane
111
Where does the urogenital diaphragm arise from?
the ischiopubuc ramus
112
Where does the urogenital diaphragm insert?
urethra, vagina, perineal body
113
What muscles attach at the perineal body?
levator anii, bulbospongiosis, superficial and deep tranvser perneii, EAS and EUS
114
What is the pelvic white line?
the tendinous arch, extends from the pubic symphysis to the ischial spine.
115
What attaches to the white line?
the endopelvic fascia (lateral attachment)
116
Where does the endopelvic fascia attach medially?
the vaginal wall
117
How does the endopelvic fascia impact continence?
the urethra is anterior and above it so during increased abdominal pressure the urethra is compressed
118
how does contraction of the pelvic floor effect the endopelvic fascia?
as the levator anii and the endopelvic fascia both attach to the white line, pelvic floor contraction also tightens the endopelvic fascia
119
What structures support the vagina?
endopelvic fascia, perineal body, levator ani muscles, perineal muscles
120
What changes to the endopelvic fascia lead to prolaspe?
tearing in vaginal birth
121
What shape is the endopelvic fascia?
a hammock
122
what kinds of prolapse are anterior compartment?
cystocele, urethrocele, cystourethrocele
123
what kinds of prolapse are apical compartment?
uterine, vaginal vault, enterocele
124
what kinds of prolapse are posterior compartment?
rectocele, enterocele
125
What is baden walker grading of prolapse?
Grade 1-4
126
What is baden walker grade 1 of prolapse?
prolapse extends halfway down vagina
127
What is baden walker grade 2 of prolapse?
prolapse to hymenal ring
128
What is baden walker grade 3 of prolapse?
Prolapse beyond hymenal ring but not maximal descent
129
What is baden walker grade 4 of prolapse?
prolapse to maximal descent
130
What is the POP Q?
pelvic organ prolapse quantification
it measures the difference between two different points for each compartment (the hymen and anatomical points), the length of the vagina, genital hiatus and the perineal body
131
what is point D on the POPQ?
the posterior fornix
132
What is point Aa on POPQ? what range can this be?
3cm proximal to the urethral meatus on anterior vaginal wall
-3 to +3
133
What is point Ap on POPQ? What range can it be?
3cm proximal from the hymen on the posterior vaginal wall
range -3 to +3cm
134
What is point Ba in POPQ? what is the least it can be?
the most distal part of the remaining anterior vaginal wall
-3cm
135
What is point Bp in the POPQ? what is the least it could be?
the most distal part of the remaining posterior vaginal wall
-3cm
136
What stage is the prolapse staged to in the POPQ?
Stage 0-4
137
what is stage 0 prolapse in the POPQ?
no prolapse, Aa, Ba, Ap, Bp are all -3cm. C is between TVL and TVL-2
138
what is stage 1 prolapse in the POPQ?
most distal point more than 1cm from hymen
139
what is stage 2 prolapse in the POPQ?
most distal point is between 1cm above and 1cm below hymen
140
what is stage 3 prolapse in the POPQ?
most distal point is more than 1cm below hymen but at least 2cm less than total vagina length
141
what is stage 4 prolapse in the POPQ?
complete vaginal eversion, <2cm vaginal wall above hymen/ more than TVL-2 out of hymen
142
How many measurement are taken in POP Q?
9
143
How many points in the vagina are marked in the POP Q?
6
144
What are the additional three lengths taken in POP Q in addition to the vaginal points?
genital hiatus
TVL
perineal body
145
What does -ve mean in POPO Q?
the point is above the hymen
146
What causes back ache in prolapse?
traction on the uterosacral ligaments
147
What urinary symptoms can prolapse cause?
stress incontinence - from urethral mobility
urge incontinence from anterior prolapse, incomplete emptying, quicker filling --> bladder irritation
voiding dysfunction - urethral kinking
UTI - incomplete emptying
148
What bowel symptoms can POP cause?
obstruction
rectal frequency and urgency - incomplete emptying
anal incontinence
149
What is used to asses symptoms severity in prolapse pre op?
Pelvic floor disability index 20
PFDI 20
150
What history should be taken with POP?
presenting symptoms
urinary and bowel symptoms
sexual function
QOL
previous treatments
MHx
Surg hx
O+G hx
FHx.
social history
151
What signs on exam for POP would increase risk POP recurrence after surgery?
varicose veins, joint hyper mobility show weak connective tissue
152
What investigations are considered in POP work up?
MSU
urodynamics
defacatory proctography
MRI
153
When would you do urodynamics in POP work up?
if planning surgery to detect SUI which may be managed under the same anaesthetic
154
When would you do a defacatory proctography in POP work up?
to differentiate entrocele or rectocele
to diagnose intersusception
if have significant anorectal symptoms with posterior prolapse
155
when would you do an MRI in work up for POP?
to differentiate other swelling from prolapse
levator ani defects
156
what non surgical management is there for POP?
physio 16 week trial
topical oestrogen
weight loss
avoid constipation
avoid heavy lifting
157
What stage prolapse POP Q can benefit from physio alone?
stage 1 and 2
158
How do pessaries work?
stretch the vagina winder than the genital hiatus so remains above the pelvic floor muscles
159
Where does a ring pessary sit int he vagina?
from the posterior fornix to the back of the pubic bone
160
Can you have sex with a ring pessary?
yes
161
What does a ring pessary rely on to work?
pelvic floor muscle tone
162
Who is a gellhorn pessary not used for?
menstruating or sexually active women
163
What is the most common type of pessary?
ring
164
If unable to tolerate a ring what is the usual next step?
gell horn
165
How often should pessaries be removed and check the vagina for ulceration?
3-6 months
166
what are complications of pessaries?
ulceration of vagina
can erode into bladder or bowel
bleeding
discharge
pain
constipation
urinary retention
167
What is the failure rate of anterior repair?
29-43%
168
What antibiotics should be used for prolapse surgery?
cover for gram +ve and -ve
169
How long should heavy lifting be avoiding after POP surgery?
3 months
170
When can SI return after POP surgery?
6 weeks
171
What is the failure rate of posterior vaginal repair?
13-22%
172
What is the a sacrospinous hysteropexy?
cervix is sutured to the sacrospinous ligament 2cm medial to ischal spine
173
What are the complications of a sacrospinous hysteropexy?
bleeding
bowel injury
infection
occult stress incontinence
buttock pain
recurrent uterine prolapse
anterior prolapse
174
What causes buttock pain in SSF and how common is it? Does it go away?
pudendal nerve or levator ani nerve impingement
2-25%
usually goes by 3 months as the suture dissolves.
1% have chronic pain
175
Which blood vessel can be injured in a SSF?
pudenal artery
176
What is the benefit to uterine preservation and sacrospinous hysteropexy?
retain uterus - fertility
shorter recovery
177
What is the down side to uterine preservation and sacrospinous hysteropexy?
higher risk of recurrence of prolapse
178
What is the manchester repair?
done for cervical descent/elongation and uterine preservation wanted
cervix amputated and cardinal ligaments resutured to support the uterus
179
What is a sacrohysteropexy?
Involves attaching back of the cervix to the sacral promontory using prolene mesh or a permanent suture
laparoscopic or open
180
What are the options for surgical management of apical compartment prolapse with uterus present?
vag hyst +/- SSF
vaginal sacrospinaous hysteropexy - sutures
manchest repair
sacrohysteropexy - mesh or sutures
181
How often does vaginal vault prolapse occur after hysterectomy for other indications?
1.8%
182
where is the SSF suture placed and why?
right side to avoid the sigmoid colon
suture placed 2cm medial from ischal spine
in older women can be half way as ligament shortens
183
What structures are lateral to the the SSF insertion?
internal pudendal artery and the pudendal nerve
184
What blood vessels are medial to the SSF point?
presacral vessels
185
What structure is promixal to the SSF point?
the sacral nerve plexus
186
What is the success rate of a SSF?
90%
187
What can happen after a SSF?
anterior compartment prolapse due to the exaggerated retroversion of the vagina
188
What is a sacrocolpopexy?
suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the fibromuscular layer of the anterior and/or posterior vaginal walls
189
what route is used for sacrocolpopexy?
open or laparoscopic
190
What are risks of sacrocolpopexy?
mesh erosion
sigmoid bowel or ureter injury (usually right)
infection
bleeding
191
What blood vessels can get injured in a sacrocolpopexy?
sacral artery
presacral venous plexus
192
What is the gold standard for vaginal vault prolapse after hysterectomy? what is the success rate?
sacrocolpoexy 93-100%
193
What is a uterosacral ligament suspension?
suspends the vaginal vault to the uterosacral ligament
194
What are the surgical options for management of vaginal vault prolapse after a hysterectomy?
SSF
sacrocolpopexy
colpocleisis
uterosacral igament suspension
195
What are the three levels of support in the pelvis?
level 1 - suspension - cardinal ligament and uterosacrals
level 2 - attachment - white line and levator ani muscle fascia
Level 3 - fusion - perineal body and urogenital diaphragm
196
What is the cloacal membrane?
temporary embryonic structure made up of the endo and ectoderm closing the hindgut. breaks down at week 7 to form the anus and urogenital openings
197
when is the anal canal and EAS established?
end of the 8th week gestation
198
What is the pectinate-dentate line?
2cm from the anal verge (inside the rectum) where the epithelium changes from the stratified epithelium to the columnar
199
What is the embryogical significance of the pectinate dentate line?
above cloaca
below from the proctodeum
200
What nerves innervate the levator anii? What level and origin?
the nerve of the levator anii S3-4
sometimes pudendal nerve S2-4
both from the sacral plexus
201
What makes up the pelvic floor?
the levator anii muscles
202
What maintains pelvic floor tone?
postural reflex of the muscles in a tonic contraction
203
What reinforces the pelvic floor anteriorly?
perineal body
204
What reinforces the pelvic floor posteriorly?
the anococcygeal body aka the fibrous medial raphe
205
What angle between the anal canal and rectum (anorectal angel) does the puborectalis create at rest ?
90 deg
206
when the puborectalis muscles relaxes during defacation what does the anorectal angle get to?
135 deg
207
What level of the spine does the rectum start?
S3
208
How long is the rectum?
15cm
209
What are the transverse fold of the rectum called? how many are there?
the valves of houston three
210
What is the ampulla rectii?
the distal part of the rectum which is usually empty, when it does fill with stool the reflex to empty is initiated
211
How long is the anal canal?
4cm
212
What makes up the IAS?
a continuation of rectal circular smooth muscle
213
How much of the resting pressure in the anal canal is from the IAS?
55-80%
214
How long is the IAS?
2.5-4cm
215
How thick is the IAS?
2mm, thinner anteriorly
216
where can you find the IAS?
spans from the pectinate line to the anal orifice
217
What maintains the tonic contraction of the IAS?
inferior hypogastric nerve plexus
SNS L1-2
alpha 2 adrenergic R
218
What allows relaxation of the IAS?
stool distending the ampulla rectii
inferior hypogastric nerve complex
PSNS S2-4
muscarinic acetyl cholinergic
219
What does EAS contribute to continence?
both voluntary squeeze and resting pressure
220
What are the two kinds of muscle fibre in the EAS?
red and white
221
What does a red muscle fibre do in the EAS?
voluntary tone but also resting tone
222
What does a white muscle fibre do in the EAS?
powerful contractions but only for a short time
223
What historically are the sections of the EAS?
deep, superficial, sub cutaneous
224
What does the EAS attach to anteriorly and posteriorly?
perineal body
anococcygeal ligament
225
What innervates the EAS? What kind of nerve is it?
inferior anal nerve S2-4
a branch of the pudendal
somatic nerve
226
What nerve innervates the puborectalis muscle? is it voluntary or involuntary
direct branch from the sacral plexus S3-4
voluntary
227
What nerve supplies sensation to the perianal skin and some of anal canal?
inferior rectal nerve from the pudendal nerve S2-4
228
What kind of mesh is recommended to use in sacrocolpopexy?
lightweight type 1 (large pore)
229
Compared with open sacrocolpopexy what outcomes does laparoscopic sacrocolpopexy have?
longer operating times
less blood loss
shorter hospital stay
same cure rate
230
What is the best graft to use in a sacrocolpopexy? why are the other inferior?
mesh
higher recurrence rate
231
For a patient having a sacrocolpopexy when should you assess for outcomes and log them?
6/12
232
What is the lifetime risk of needing surgery for POP? RANZCOG
19%
233
What is the reoperation rate for POP? RANZCOG
up to 25%
234
What can be done to reduce the risk of recurrent prolapse? Why?
apical support, at least half of anterior compartment support is from apical support
235
What are risk factors for pelvic organ prolapse recurrence?
* Parity
* Vaginal birth
* Age
* High BMI
* Preoperative clinical stage
* Preoperative symptom severity
* Family history
* Connective tissue disorders
* Presence of levator avulsion
* Surgeon experience
236
Why is sacrocolpopexy the gold standard of prolapse repair after hysterectomy?
compared to other prolapse treatments lower risk of recurrent symptoms or signs of exam, need for repeat surgery, post operative stress incontinence and dyspareunia
237
Compared to SSF what outcomes does sacrocolpopexy have?
higher anatomical success, less SUI, less post op dyspareunia
but
great surgical morbidity
238
re sacrocolpopexy what outcomes does robotic have compared to laparoscopic?
more expensive, longer
similar outcomes and risks
239
when discussing informed consent for sacrocolpopexy what principles should be used?
shared decision making, wide range discussion including
general surgical risks
specific surgical risks
de novo SUI
other options
specific mesh discussion and risks
240
What are the specific surgical risks of sarcocolpopexy?
exposure of mesh 3%
injury to bowel 1.4%
bladder injury 1.8%
ureter injury
osteomyelitis or sacral discitis <1%
dyspareunia
pelvis pain
change to bowel or urination (occult SUI)
241
What are mesh complications?
erosion, vaginal scarring/stricture, fistula, dyspareunia, unprovoked pain at rest. May need further surgery
242
Who is at high risk of occult SUI after SCP?
older women
low maximum urethral closure pressure
positive pessary leak test
243
Who should sacrocolpopexy be reserved for?
severe prolpase
high risk recurrence
recurrence after vaginal surgery
244
What anaesthetics is best to optimise patient pain in SCP?
GA and spinal
245
What antibiotic regime should be used for SCP?
one dose in OT only
246
What laxatives should be used for sacrocolpopexy?
multiple agents
247
What is the recommended MUS approach for most patients?
retropubic MUS
248
What is a mid urethral sling?
a narrow synthetic polpropylene mesh tape placed beneath the middle part of the urethra to provide dynamic support to the urethra, preventing urinary leakage with exertion
249
what risks are increased with transobturator MUS?
groin and pelvic pain, may need removal
250
what risks are increased with retropubic MUS?
visceral injury
251
what are the benefits of retropubic approach to MUS over transobturator?
possibly better longer term outcomes
more effective in intrinsic sphincter deficiency
lower post op pain
can usually remove the mesh if needed
lower rate of re operation needed
252
What are the down sides to retropubic sling approach MUS?
longer hospital stay
higher risk of post operative voiding dysfunction
higher risk of visceral injury (including blood vessel)
253
What outcomes are similar with TO and RP MUS?
short and medium success rates
mesh erosion
254
What is the % risk of mesh erosion with MUS?
2%
255
What is first line treatment for SUI?
bladder retaining and PFME
256
Which patient should be offered the TO MUS?
extensive pelvic/abdominal surgery
women unable to cease anticoagulation
women with compromised voiding pre operatively
257
Prior to MUS what investigation should be considered and why?
urodynamics
exclude other causes of urinary incontinence, exclude voiding dysfunction and evaluate for intrinsic sphincter deficiency
258
What variable can effect the success of an MUS?
patient BMI
259
What complications should be discussed prior to MUS?
bleeding, injury to viscera, blood vessels, voiding difficulty incl self catheterisation, loosing or removal of sling may cause recurrence SUI
de novo urge incontinence or worsening
pain - dyspareunia
260
How common is chronic pain after a MUS?
5%
some is debilitating
261
Why is the mesh thought to erode?
an oxidative reaction
262
How often do women need the MUS removed for pain? How many does this cure pain for?
1 in 150
81% have pain resolution
263
The NZ non-Mesh Stress Urinary Incontinence Surgery guideline requires 5 steps be undertaken prior to operating, what are they?
1. adequately skilled surgeon
2. physio for at least 12 weeks unless strong coordinated pelvic floor activity demonstrated
3. full pre op assessment including urodynamics
4. shared decision making and informed consent with a decision aid
5. MDT discussion of plan
264
Which compartment prolapse is mesh advantageous in? What are the advantages?
anterior
lower risk of re operation
reduction in prolapse symptoms
265
What % of patients that have vaginal mesh have exposure in the vagina?
8-15%
266
What are the risks of vaginal mesh which offset any advantages?
higher overall reoperation for prolapse, UI, mesh exposure, bladder injury, SUI, prolapse at other sites
267
When was mesh introduced for vaginal surgery and when did problems become evident?
2002
2008
268
is vaginal mesh useful for posterior or apical prolapse?
no it is no better than native repair
269
What alternative surgery is there to vaginal mesh?
native repair
sacrocolpopexy
SSF
270
What vaginal mesh complications are there?
mesh exposure/erosion, vaginal scarring/stricture, fistula formation, dyspareunia, pelvic pain including unprovoked
271
In NZ who do we report adverse events of mesh?
MEDSAFE
272
Who may benefit from vaginal mesh implant?
young patients
obese
stage 3/4 prolapse
chronic raised intrabdominal pressure
273
What is function of the rectum?
act as a reservoir for stool for a short period of time to allow voluntary defacation
274
What is the function of the anal canal?
to maintain continence
275
What controls anal continence?
IAS, EAS, and pelvic floor
276
What reflexes are involved in defacation?
gastrocolic reflex
rectoanal inhibitory reflex
277
What is the rectoanal inhibitory reflex?
sensation of a full rectum is perceived by the cerebral cortex and relaxation of the IAS occurs
this leads to contact of receptors in the upper anal canal
278
after the rectoanal inhibitory reflex what is needed for defacation?
relaxation of the EAS, puborectalis sling and pelvic floor
279
What does contraction of the puborectalis do?
makes the ARA more acute
lifts the pelvic floor
elongates the anal canal longer
280
What is dyssynergic defecation?
increased intraanal pressure with attempt of defecation + impaired rectal emptying
281
What is dyssyndergic defacation caused by?
failure to relax IAS and puborectalis
282
What is commonly associated with obstructive defacatory symptoms?
rectocele
unclear if cause or effect
283
What is thought to cause obstructive defecatory symptoms?
impaired rectal filling sensation
plus functional outlet obstruction
284
What is the difference between anal and faecal incontinence?
anal - flatus, faeces
faceal - faecal only
285
How common is levator anii avulsion with vaginal birth?
up to 35%
286
What is the common common cause of faecal incontinence?
OASI
287
What does anorectal manometry assess?
pressure, muscle tone, coordination or sphincters and rectum
information or sensory and reflex mechanisms
288
What is Anorectal manometry used for assessing?
faecal incontinence - EAS and IAS pressure
constipation
pelvic floor dyssynergia
289
In ARM what is the squeeze pressure mainly created by?
EAS - so if low EAS damaged
290
In ARM what is the resting pressure mainly created by?
IAS - if low damaged
291
What are the four layers assessed on endoanal USS?
sub epithelial layer
IAS
conjoint longitudinal muscle
EAS
292
is the EAS symmetrical all the way round?
no it is shorter anteriorly
293
what level is the anorectal angle at?
the ischial tuberosities
294
Who may benefit from a defacating proctogram?
constipation
obstructive defecating symptoms - assessing prolapse and pelvic floor descent
295
What contrast is used in a defecating proctogram?
barium oral and rectal
296
What conservative management is there for faecal incotninence?
constipating agents - codeine, loperamide
biofeedback/bowel training
neuromodulation - sacral or posterior tibial nerve stimulation
297
What are the risks of oral fluconazole in pregnancy?
associated with T1
miscarriage
cardiac septal closure problems in doses >150mg
298
What is POP Q stage 0 prolapse?
no prolapse, Aa, Ba, Ap, Bp are all -3cm and C and D less than (TVL-2cm)
299
What is POP Q stage 1 prolapse?
leading edge <-1cm
300
What is POP Q stage 2 prolapse?
leading edge >-1cm but < +1cm
301
What is POP Q stage 3 prolapse?
leading edge >+1cm but
302
What is POP Q stage 4 prolapse?
leading edge >TVL-2cm
303
When should you consider urodynamics in SUI?
pre any surgery for SUI
if previous surgery which has failed
if voiding dysfunction present
previous RT
suspected neurological disease
304
How common is anterior wall prolapse after SSF?
20-30%
305
What centres are involves in micturition?
pontine micturition centre
peri aqueductal grey
cortical centres
306
What does the periaqueductal grey do in micrturition?
inhibits the pontine micturition centre to allow filling and inhibits the pelvic nerve (contraction). When the bladder is full it communicates with the frontal lobe about when is appropriate to urinate. When the right time is found it removed inhibiton on the PMC.
307
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
-
Week 419
-
Week 585
-
Autoimmune medications and pregnancy11
-
Landmark trials to date13
-
Week 6253
-
Week 7259
-
Week 8232
-
Week 9206
-
Week 10364
-
Week 258
-
week 371
-
Week one136
-
Week 11237
-
Week 12314
-
Week 13381
-
GONC 1395
-
GONC 2259
-
Week 16134
-
Week 17410
-
Week 18266
-
Week 19347
-
Week 20307
-
Week 21430
-
Week 22370
-
Week 23298
-
Week 24325
-
Week 261
-
Key Links
-
Subjects
-
Company
-
Find Us
-
