Urogynaecology and pelvic floor

Question 1

Causes of a vesicovaginal fistula

Answer 1

Obstructed labour
Following benign gynaecology surgery - e.g TAH
Following surgery for gynaecological malignancy
Pelvic radiotherapy
Pelvic TB
Vaginal erosion of a neglected foreign body e.g. Pessary

Question 2

First management of genuine stress incontinence

Answer 2

Lifestyle measures
and
Pelvic floor physiotherapy

Question 3

Management of genuine stress incontinence

Answer 3

Lifestyle measures + Weight loss
Pelvic floor physio
Surgical options - Midurethral sling / Pubovaginal sling/ Colposuspension (bladder neck suspension)

If wants to avoid surgery consider
Duloxetine (SNRI)
Oxybutynin or tolterodine (anticholinergic)
Vaginal estrogen if atrophic

Question 4

Dietary modification suggestions for urge incontinence

Answer 4

Citrus fruits and flavourings 
Acidic PH 
Caffeine
Spicy foods and chillis 
Chocolate 
Fizzy drinks 
Artificial sweeteners

Question 5

1st line treatment for overactive bladder

Answer 5

Oxybutynin

Question 6

What patient group should oxybutynin be avoided

Answer 6

Oxybutynin shouldn’t be given to frail elderly patients

Question 7

Management of OAB prior to initiating anticholinergics

Answer 7

Prior to initiating anticholinergics

• Bladder training
• Consider treating vaginal atrophy and nocturia with topical oestrogen
• desmopressin

Question 8

First line OAB anticholinergics

Answer 8

1st line treatments:

1. Oxybutynin (immediate release)
2. Tolterodine (immediate release)
3. Darifenacin (once daily preparation)

Mirabegron, if an antimuscarinic is contraindicated

Question 9

What is the stepwise approach to managing stress incontinence

Answer 9

stress incontinence treatment should follow a stepwise approach:

Lifestyle measures

Pelvic floor training

Consider invasive procedures

Question 10

When should women be referred to the urogynaecology MDT

Answer 10

women with primary stress urinary incontinence, overactive bladder or primary prolapse should be referred for MDT review if

• offered invasive procedures for primary stress urinary incontinence, overactive bladder or primary prolapse
• Regional MDTs deal with complex pelvic floor dysfunction and mesh-related problems

Question 11

Categories of urinary incontinence

Answer 11

stress urinary incontinence,

mixed urinary incontinence

urgency urinary incontinence/overactive bladder.

Question 12

In mixed urinary incontinence what should treatment be directed at first?

Answer 12

direct treatment towards the predominant symptom

Question 13

Lifestyle interventions for urinary incontinence

Answer 13

Lifestyle interventions for urinary incontinence

A trial of caffeine reduction to women with overactive bladder

Advise women with a high or low fluid intake to modify their fluid intake

Advise women who have a BMI greater than 30 to lose weight

Question 14

Non-surgical management of urinary incontinence

Answer 14

Lifestyle interventions 
     - reduce caffeine
     - reduce fluid intake if high
      - reduce BMI if >30
Pelvic floor training 
Bladder training

Question 15

What should Pelvic floor muscle exercises comprise of?

Answer 15

at least 8 contractions performed 3 times per day

Question 16

When should electrical stimulation and/or biofeedback for pelvic floor exercises be considered

Answer 16

for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy

Question 17

When should bladder catheterisation be considered for management of urinary incontinence

Answer 17

If persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction
and cannot otherwise be corrected.

intermittent catheterisation to women with urinary retention who can be taught or have a carer who can

long-term indwelling urethral catheters for women

• unable to self catheterise
  - skin wounds, pressure ulcers, irritations being contaminated by urine
  
  • distress / disruption caused by bed / clothing changes
    
    • patient preference

Indwelling suprapubic catheters considered as alternative to long-term urethral catheters

Question 18

NICE guidance on complementary therapies for urinary incontinence

Answer 18

Do not recommend complementary therapies for the treatment of urinary incontinence or overactive bladder.

Question 19

When should transdermal treatment be offered for overactive bladder?

Answer 19

Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines

Question 20

When may desmopressin be considered for women with incontinence?

Answer 20

desmopressin may be considered specifically to reduce

nocturia

in women with urinary incontinence or overactive bladder who find it a troublesome symptom

Question 21

When may duloxetine be offered as a treatment for women with stress urinary incontinence

Answer 21

Do not routinely offer duloxetine as a second-line treatment for stress urinary incontinence

may be offered second-line if women prefer pharmacological to surgical treatment

or are not suitable for surgery

Question 22

What type and when are hormonal treatments advocated by NICE for women with incontinence

Answer 22

Offer intravaginal oestrogens postmenopausal women with vaginal atrophy
and
overactive bladder symptoms

Question 23

When should Botox be offered for urinary incontinence

Answer 23

offer bladder wall injection
For overactive bladder caused by detrusor overactivity

that has not responded to non-surgical management, including pharmacological treatments

Consider for overactive bladder without detrusor overactivity if the woman does not wish to have other invasive treatments.

Question 24

What type of Botox is used for urge incontinence with detrusor overactivity?

Answer 24

bladder wall injection

with botulinum toxin type A

= longer duration of effect than type B

Question 25

when should Percutaneous sacral nerve stimulation be offered for urinary incontinence

Answer 25

offer percutaneous sacral nerve stimulation
if overactive bladder has not responded to non-surgical management including medicines
AND
have not responded to botulinum toxin type A
OR
they decline Botox

Question 26

What types of surgery does NICE recommend for managing stress urinary incontinence?

Answer 26

NICE recommends 3 types of surgery for managing stress urinary incontinence if other treatments failed

• colposuspension
• autologous rectus fascial sling
• a retropubic mid-urethral mesh sling (tape)

Question 27

Does colposuspension or a retropubic mid-urethral mesh sling carry a higher risk of subsequent pelvic organ prolapse?

Answer 27

Pelvic organ prolapse more likely after colposuspension than a retropubic mesh sling

Question 28

What happens in colposuspension surgery?

Answer 28

It involves lifting up the tissue around the neck of the bladder, and suspending it in this lifted position using synthetic stitches

Permanent or dissolvable

Question 29

What is done In a Rectal fascial sling operation?

Answer 29

A sling is made using the rectus fascia from the abdomen.

The sling is placed behind the urethra to support it.
And stitched to the inside of the abdomen

Question 30

What is done in a recto-pubic mesh sling?

Answer 30

This involves placing a strip of synthetic mesh behind the urethra to support it in a sling

The strip of mesh sometimes called a tape.

mesh is permanent

Question 31

lifestyle advice for women with pelvic organ prolapse

Answer 31

losing weight, if BMI > 30

minimising heavy lifting

preventing or treating constipation

Question 32

What is mirabegron?

Answer 32

Mirabegron= selective beta 3 agonist

relaxes the bladder detrusor muscle and enhances urine storage

licensed for OAB if antimuscarinic CI