Prolapse & Incontinence.txt

  1. what causes uterine prolapse (basic path)
    laxity of ligaments: transverse cervical, uterosacral
  2. what is 1st degree prolapse?
    cervix is still within the vagina
  3. what is 2nd degree prolapse?
    cervix is at introits
  4. what is 3rd degree prolapse?
    entire uterus comes out
  5. what is vault prolapse?
    if uterus has been removed, the vault=top of vagina where uterus used to be can prolapse
  6. what causes bladder/bowel prolapse?
    levator ani muscle weakness (floor of pelvis)
  7. what is cystocele?
    bladder prolapse through anterior vaginal wall
  8. what is rectoceled?
    prolapse rectum through posterior vaginal wall
  9. what is enterocele?
    • prolapse of pouch of douglas ie peritoneal cavity into posterior vaginal wall just behind the uterus
    • usually contains small bowel
  10. what are symptoms of prolapse?
    • draggging sensation
    • lump between legs
    • lower back pain
    • vaginal discomfort
    • painful intercourse
    • PCB
  11. what are symptoms of cystocele?
    • freq
    • incontinence
  12. what are symptoms of rectocele?
    difficulty defaecating
  13. which age group get prolapse and why?
    • post menopausal
    • as oestrogen deficiency causes atrophy of pelvic supports and vaginal walls
  14. what needs to be asked in gynae hx?
  15. what are risk factors for prolapse?
    • menopause
    • hysterectomy
    • vaginal deliveries
    • multiparity
    • obesity
    • chronic cough - smoker
    • consipation
    • ie last 3 = increased IAP
  16. what examination needs to be done in suspected prolapse?
    sims speculum
  17. what is conservative Rx of prolapse?
    • weight loss
    • treat cough - stop smoking
    • treat constipation
  18. what is medical Rx of prolapse?
    • pessaries = artificial pelvic floor in vagina - stay behind pubic symphysis
    • ring or shelf (more severe)
    • change every 3-6 months
    • oestrogen therapy for post menopausal - topical or systemic
  19. what are problems with pessaries?
    • pain
    • urinary retention
    • infeciton
    • fall out
    • bleeding
  20. what is surgical Rx if major 3rd degree uterine prolapse?
    vaginal hysterectomy
  21. what is Rx of vaginal vault prolapse? give 2 options and route of each
    • sacrospinous colpopexy - suspension of vault to sacrospinous ligament. vaginal route
    • sacrocolpopexy - fixation of vault to sacrum using a mesh = abdominal route
  22. what is Rx of cysto/rectocoele?
    • anterior or posterior repair
    • may need mesh for support
  23. what is definition of urinary incontinence?
    involuntary loss of urine that causes a social problem
  24. what are RF for incontinence?
    • pregnancy
    • vaginal delivery
    • prolonged labour
    • forceps
    • obesity
    • age - post menopausal
    • previous hysterectomy - predispose to SUI
    • diuretics
    • coffee, alcohol
  25. what is cystometry?
    • catheter in bladder - measure pressure
    • pressure transducer in rectum
    • fill
    • cough
  26. how is detrusor pressure calculated?
    bladder pressure - abdo pressure
  27. on cystometry how can you tell between SUI and OAB?
    OAB: get involuntary detrusor contractions - so detrusor pressure increases spontaneously, also can be provoked eg by cough
  28. should all pt with UI have cystometry?
    • no until failure of lifestyle, medical Rx
    • ie only if planning surgery
  29. what is conservative Rx for SUI?
    • pelvic floor muscle training
    • 8 contractions tds
    • vaginal cones - held in position by voluntary muscle contraction (increased size to inc strength)
  30. what is medical Rx for SUI?
    • duloxetine SSRI
    • but SE gastric headache suicide
  31. what is the aim of surgical Rx for SUI?
    to transmit the raised IAP to bladder neck as well as bladder
  32. what is surgical Rx for SUI?
    • TVT
    • TOT
    • gold standard: burch colposuspension
  33. what are risks of TVT? so what needs to be done before surgery
    • retention
    • bladder perforation
    • detrusor instability - so do cystometry to exlcude OAB
    • erosion
  34. what is burch colposuspension?
    • bladder neck lifted using sutures
    • placed via abdominal incision
  35. what is main symptom of OAB?
    • frequent passage of small vol of urine
    • esp at night
  36. what is conservative Rx for OAB - 2
    • reduce caffeine, fluid intake
    • bladder training - void by clock. increased intervals
  37. what is medical Rx for OAB?
    • anticholinergics
    • SE
    • oxybutinin, tolerotine, solifenacin
  38. after tablets, what can be done for OAB?
    • botox A injection into detrusor muscle
    • sacral nerve stimulation
  39. what is risk of botox injection?
    • total bladder paralysis
    • need for intermittent self catheterisation
  40. what is surgical Rx of OAB?
    clam augmentation ileocystoplasty
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Prolapse & Incontinence.txt