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

i) Urge Incontinence

This is the 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 

Management (NICE1):

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

For Urge Incontinence:

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

2nd line = Antimuscarinics: Oxybutynin, Tolterodine, or Darifenacin

3rd line = Mirabegron (B3 agonist) if antimuscarinics are contraindicated

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

For Stress Incontinence:

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

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

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