Urogynaecology
  • Urinary Incontinence

This is a very important gynaecological condition which has a huge impact of patients’ lives.
– There are two main types of incontinence in females, each of which have different pathologies and treatments.
– It affects about 4-5% of the population, being more common in elderly females

Risk factors
– The biggest risk factor for all types of urinary incontinence is old age

 

i) Urge Incontinence ➔ Involuntary leakage preceded/accompanied by a sudden desire to pass urine
– It occurs due to an overactive bladder due to increase detrusor muscle overactivity

Causes:
Mostly idiopathic but can be associated with neurological conditions (e.g. MS, PD)
– Can be made worse by diuretics, coffee, alcohol, concurrent UTIs

 

ii) Stress Incontinence ➔ Involuntary leakage upon increased intra-abdominal pressure (e.g. coughing, sneezing)
– It occurs due to weakening of the pelvic floor muscles, so they do not compress the bladder neck

Causes:
Pregnancy, vaginal delivery, obesity (these all weaken the pelvic floor muscles)

 

Tests
– These are needed to distinguish between the two main types of incontinence
– Abdominal examination –> to look for palpable, enlarged bladder suggesting retention
– Vaginal examination –> to assess pelvic muscle tone and look for prolapse (a sign of pelvic floor weakness)
– Urine dipstick –> to check for UTI
– Bladder diaries –> Ask to patient to complete a bladder diary for a minimum of 3 days
– It allows you to see if there are any triggers and how much fluids patients drink

 

These tests are usually sufficient to determine type of incontinence. If unclear, then:

Urodynamic studies: This tests pressure changes of the detrusor muscle with a fluid challenge
– Put one pressure sensor in the bladder to measure intra-bladder pressure
– Put second sensor in the vagina/rectum to measure intra-abdominal pressure
– If you take the difference, then it allows you to work out the true detrusor pressure

a) Urge incontinence:

– You ask the woman at what volume filled in the bladder she feels the first urge to go to the toilet.
– If overactive bladder, the bladder and detrusor pressure will
increase at a low filling volume and cause leakage, without
any increase in abdominal pressure.

 

b) Stress incontinence:

– A cough or Valsalva will cause a rise in abdominal pressure
– This is transmitted so that intra-bladder pressure also rises
– The true detrusor pressure stays zero as it is not contracting – Usually there should be no leakage of urine from the bladder
– However, in stress incontinence a cough causes leakage without causing a rise in detrusor pressure
– This therefore shows that that the leakage is due to weakness of the pelvic muscles, rather than detrusor muscle overactivity

Management (NICE1):
– Common to both types, reduce caffeine, regulating fluid intake, weight loss (if BMI 30+) and stop smoking

 

Urge ➔ 1st line = Bladder retraining (at least 6 weeks)

– 2nd line = Antimuscarinics: Oxybutynin, Tolterodine, or Darifenacin
– 3rd line = Mirabegron (B3 agonist) if antimuscarinics are contraindicated
– 4th line = Secondary care treatments:
• Botox —> Dangerous side effect is urine retention, so patients must be willing to self-catheterize.
• Sacral nerve stimulation —> used for women who refuse to have catheters with Botox

 

Stress ➔ 1st line is Pelvic floor muscle exercises (3-month trial of 8 contractions, 3 times a day)

– 2nd line = Surgery -> options include:
• Autologous rectal fascial sling: abdominal wall fascia is used to form a sling around the urethra
• Retropubic mid-urethral mesh sling: procedure in which mesh is used as a urethral sling
• Intramural bulking agents: silicone injection which adds bulk to urethral sphincter (wears off)
• Colposuspension: procedure in which the bladder neck is tethered to the surrounding tissues
– 3rd line = if the patient does not want surgery, offer duloxetine

 

 

  • Urogenital Prolapse

This refers to a descent of one of the pelvic organs resulting in protrusion on the vaginal walls
– It is most often due to childbirth
– It is defined by the organ which protrudes on/out of the vagina.
– Bladder = Cystocele
– Uterus = Uterine prolapse
– Rectum = Rectocele
– Procidentia = Whole uterus + Cervix

 

Risk factors
– Weakening of the pelvic floor -> older age, pregnancy and vaginal delivery, obesity

 

Symptoms
– Dragging discomfort/sensation of heaviness in the vagina
– Feeling that something is coming out of the vagina –> patient may be able to feel a protruding bulge
– Urinary symptoms –> increased frequency, incomplete emptying, stress incontinence

 

Staging – It is staged according to the distance the organs reach from the hymenal ring – Stage 1 = when you can displace the uterus but not up to 1cm of the vaginal opening
– Stage 2 = when the prolapse reaches the hymenal ring
– Stage 3 = when the prolapse reaches 1cm out of the hymenal ring
– Stage 4 = When the whole organ prolapses out of the vagina

 

Tests:
– Speculum examination ➔  Ask the patient to adopt the left lateral position and insert a Simms speculum
– After insertion, ask the patient to cough raising abdominal pressure

– Bimanual examination ➔ Uterus is more mobile and moveable

 

Management

– 1st line is pelvic floor exercises (8 contractions, 3 times/day for 3 months)
-2nd line is pessary ➔  This must be changed every 6 months and gives small risk of urinary retention
– If rectal or bladder prolapse –> use ring pessary
– If uterine –> use shelf pessary

 

 

 

 

– 3rd line is surgical repair:
– Cystocele ➔ Anterior repair
– Rectocele ➔ Posterior repair
– Uterine ➔ Laparoscopic hysteropexy
– 4th line is Hysterectomy

 

– If stage 4 prolapse ➔  sacral-spinous fixation (SSF)
–> Organs are fixed to the sacrum and spinous processes completely immobilising them
–> Risk of bleeding due to damage to pudendal venous plexus + bad buttock pain due to irritation to the pudendal nerve

  • Pelvic Inflammatory Disease (PID)

An inflammatory condition affecting the pelvic organs like the uterus, oviducts, ovaries and peritoneum
– It is usually caused by ascending sexually transmitted infections which arise from the endocervix
– Chronic inflammation gives scarring and fibrosis which leads to pain and menstrual problems

Causes:
Chlamydia trachomatis (most common), Neisseria Gonorrhoea, Mycoplasma genitalium

Symptoms:
– Fever
– Pelvic + lower abdominal pain
– Deep dyspareunia (different to the superficial dyspareunia experienced in menopause)
– Vaginal/cervical discharge

 

– Abnormal vaginal bleeding
– On bimanual examination -> adnexal tenderness, cervical excitation (pain elicited when two fingers used to move cervix), abnormal discharge

N.B. If untreated, can lead to Fitz-Hugh Curtis syndrome ➔ RUQ pain
– Other complications of PID include increased risk of infertility, chronic pain and ectopic pregnancy

Diagnosis
– clinical diagnosis is made, and treatment started before test results
– 1st do pregnancy test to exclude ectopic pregnancy
– High vaginal swab and Chlamydia and Gonorrhoea tests
– Blood tests –> show raised WBC and high CRP/ESR

 

Management
– BNF2 recommends 14-day course of:
– Doxycycline + metronidazole + single-dose IM ceftriaxone or
– Ofloxacin + metronidazole
– If severe –> start with doxycycline + IV metronidazole + IV ceftriaxone

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