Female Urology - American Urological Association

Female Urology
Firouz Daneshgari, M.D.
Outline For FPM&RS Board
1. Pelvic Floor Anatomy
2. Physiology of the lower urinary tract
3. Physiology of Uterurs, Vaginal and Colorectal
System
4. General Pelvic Floor Evaluation
5. Urodynamic Assessment of Urinary
Incontinence
6. Surgery for Stress Urinary Incontinence
Outline For FPM&RS Board
7. OAB syndrome/refractory urge
8. Surgery for POP
9. Fecal Incontinence- Dx and Tx
10.Non-surgical tx of POP
11.Augmenting surgical material for pelvic
reconstruction
12.Peri-operative management
13.LUT fistula
14. Rectovaginal Fistula
15.Urethral diverticula
Outline For FPM&RS Board
16.Congenital anomalies of the Urogenital
System
17.Intra-op care and management of injuries to
bladder, ureter and Bowel
18.UTIs
19.Neuro-urology
20.Painful bladder syndrome and IN.C.
21.Statistics and scientific dissemination
AUA Guidelines for Female Urology
•
•
•
•
•
•
Asymptomatic Microhematuria
Adult Urodynamics
Incontinence
I.C. Painful Bladder Syndrome
Overactive Bladder
BPH
Voiding Dysfunction & NeuroUrology
Female Urology
•
•
•
•
•
•
•
•
Asymptomatic Microhematuria
Adult Urodynamics
Incontinence
I.C. Painful Bladder Syndrome
Overactive Bladder
BPH
Neurogenic Bladder
Pelvic Organ Prolapse
Outline for 2nd Session
• Incontinence
• Overactive Bladder
• Pelvic Organ Prolapse
INCONTINENCE
Surgical Burden of FPFD
• Over 250,000. Surgical cases of SUI
• 490,000 Cases of FPFD surgical repairs in
1995-1997
• One third of surgical procedures are done for
recurrent cases
• The figures are going to increase 2-3 folds (at
least) before 2015
Theories on Pathophysiology of SUI in Women
• Position of proximal urethra1
• Intrinsic sphincter/bladder neck2
• Hammock hypothesis3
• Integral theory4
• Trampoline Theory5
1.
2.
3.
4.
5.
Enhorning GE. Urol Int. 1976;31(1-2):3-5.
McGuire 1993
DeLancey JOL. Am J Obstet Gynecol. 1994;170(6):1713-1720.
Ulmsten U, Petros P. Curr Opin Obstet Gynecol. 1992;4(3):456-462.
Daneshgari- BJUI- 2005
Urethral Position Theory
Gillenwater JY. Adult and pediatric urology. 1996;2.
Marshall Marchetti Krantz
Intrinsic sphincter deficiency (ISD)
Urethra is unable
to generate
enough outlet
resistance to
retain urine in
bladder
Normal
Closed
Abnormal
Closed
Hammock Hypothesis
Pubovaginal Sling
• 4 Surgical Principles:
1. Hammock support of the
bladder outlet by an additional
strip of tissue.
2. Position of the hammock
support at the bladder outlet.
3. Fixation of the hammock
support to an anatomical
landmark.
4. Appropriate tension applied to
the hammock support at the
bladder outlet.
Integral Theory
Resting closed
Active closed
Ulmsten U, Petros P. Curr Opin Obstet Gynecol. 1992;4(3):456-462.
Open
Mid Urethral Slings
Outcomes of Anti-Incontinence Procedures
Cure
Improved
Complications
Emptying dysfunction
Detrusor overactivity
Burch1
77-89%
5%
20%
2-27%
8-27%
Sling1
73-99%
6%
31%
2-37%
17%
TVT2 Implants3
68-91% 59-69%
7-26%
16-25%
15-20%
6%
7%
7-11%
1. AHCPR. Rockville, Maryland: US Dept of Health and Human Services; 1996. 96-0682; Black NA, Downs SH. Br J Urol.
1996;78(4):497-510; AUA. Female Stress Urinary Incontinence Clinical Guideline Panel; 1997; Miklos JR. Presented at:1st
International Consultation on Incontience; June 28-July 2, 1998; Monaco;
Weber AM, Walters MD. Obstet Gynecol. 2000;96(6):867-873.
2. Ulmsten U, et al. Int Urogynecol J Pelvic Floor Dysfunct. 1998;9(4):210-213.
3. AHCPR. Rockville, Maryland: US Dept of Health and Human Services; 1996. 96-0682.
Predispose
GENDER
NEUROPATHY
ANATOMY
Connective Tissue
Environmental
Genetic
Muscular
Racial
INCITE
CHILDBIRTH
Habit & Training
Nerve Damage
Radiation
Smoking
Surgery
Tissue Disruption
Promote
AGING
Constipation
Lung Disease
Menopause
Occupation/Recreation
Smoking
Surgery
Incontinent
Intervene
Behavioral
Pharmacologic
Surgical
Continent
INCONTINENCE PARADIGM
Decompensate
AGING
Dementia
Debility
Disease
Environment
Medications
Infection
Trampoline
Theory
striated
muscle
smooth
muscle
brain
signals
pelvic floor
support
spinal cord
signals
vaginal wall
support
connective
tissue
rhabdosphincter
vasculature
Daneshgari 2005
intracellular
contractile
apparatus
Trampoline
Theory
Striated
muscle
Smooth
muscle
brain
signals
pelvic floor
support
vaginal wall
support
spinal cord
signals
rhabdosphincter
vasculature
Connective
tissue
Daneshgari 2005
Intracellular
contractile
apparatus
Case-1
• 67 y female presents with 6 months
hx of mixed urinary incontinence, frequency
and urgency.
• Signs:
• Bladder Diary:
– Daytime frequency: 14
– Nocturia: 4
– Voided volume: 150 (average); 24 hr voided volume:
1500 ml
– Incontinence episode: 4/day; 20/week
• Physical Exam:
– Stress UI
– AVW POP Stage III, No PVWP
• Pad Test:
– >20 gm difference in 24 hr pad test
Case-2
• 46 y female with one year history of SUI
during aerobic exercise and lifting
• Signs of:
• Bladder Diary:
– Daytime frequency: 8
– Nocturia: 0-1
– Voided volume: 300 (average); 24 hr
voided volume: 1500 ml
– Incontinence episode: 0-1/day; 5/week
• Physical Exam:
– No Stress UI
– Stage II PVW POP
• Pad Test:
– 2 gm difference in 24 hr pad test
Case #3
• 32 y female with c/o frequency, urgency.
• No incontinence, hx of UTIs
• Urethral Syndrome
Case #4
• 46 y AA female with c/o recurrent UTIs +/feeling of a vaginal buldge
• DD of Vaginal Mass
Differential Dx
•
•
•
•
•
•
• Skene’s gland
cyst/abscess
• Vaginal wall cyst
(inclusion cyst,
mullerian…)
• Ectopic ureterocele
• Malignancy
POP
UTI
Vaginal leiomyoma
Urethral diverticulum
Gartner duct cyst
Bartholin duct cyst
27
28
29
30
• Imaging
31
• Imaging
32
Case #5
• 66 y female with c/o
vaginal bulge
• Options for surgical
management of stage
IV POP:
– Abdominal SC
– Colpocleisis
FPM&RS
Simplified
• Anatomical Anomalies
• Functional Anomalies
• Patient Expectation and Engagement (Patient
Reported Outcomes- PROs)
FPM&RS
Simplified
• Anatomical Anomalies
– Pelvic Exam
• Functional Anomalies
– Bladder Diary
– UDS :
•
•
•
•
OAB
Stress
Mixed
Others- Urethral Syndrome
• Patient Expectation and Engagement (Patient
Reported Outcomes- PROs)
Pelvic Organ Prolapse Grading System (POPQ)
Severity
assessment
Vaginal
profile
Grading
system
Quantitative
POP
Porges – 1963
Baden-1972
Beecham-1980
ICS/AUGS-1996
straining
Mild
Grade I
1st Degree
Stage 1
-1cm
Grade II
hymen
Stage 2
introitus
+1cm
At rest
Moderate
Grade III
Severe
Grade IV
2nd Degree
Complete
eversion
3rd Degree
Stage 3
Stage 4
Pelvic Organ Prolapse Quantitation
POP-Q Landmarks
1. Fixed reference point: Hymen
2. 9 defined points of measurement
(Aa, Ba, etc)
3. Above hymen negative (-) cm
4. Below hymen positive (+) cm
A, B, C of the POP:
A:
- U-V junction
- -3 cm from the hymen
- anterior wall: Aa
- posterior wall: Ap
B:
- Most Advanced Point
- 6 cm from the hymen
anterior wall: Aa
posterior wall: Ap
C:
- Depth of vagina
POP-Q System
Vaginal Vault Prolapse
+10 +8
+6
+4
+2
0
-2
-4
Aa
C Bp
Ba
Ap
-6
-8
-10
SSLF
Uterosacral Ligament Fixation
USLF
Competition
• Abdominal
–
–
–
–
–
–
–
–
• Vaginal
93-100% long-term success
Mean hospital stay 6 days
Mean EBL 500ml
Mean OR time 133 minutes
Mean hospital cost $8048 + 2600
Delayed return to work/activity
Low rates dyspareunia
Maintenance of vaginal length
–
–
–
–
–
–
–
–
60-76% long-term success
Mean hospital stay 2 days
Mean EBL 200ml
Mean OR time 78 minutes
Mean hospital cost $6537 + 851
Quicker return to work/activity
Higher rates of dysparuenia
Vaginal shortening
Cochrane Data Base 2004; Maher 2007; Ng et al 2004;
Brubaker et al: NEJM. 2006: 354: 1557-66
Goals of Repair of VVP
• Anatomical Goals
• Visceral function (sexual, urinary, stool)
In addition:
• Meet Patient’s expectation- Quality of Life
• Minimize complications
• Minimize recurrence
Prolapse Surgery
Potential Complications
 Recurrence of Prolapse
 Development of new prolapse in other segments
 Visceral Dysfunction:
 Urinary incontinence/voiding dysfunction
 Sexual dysfunction
 Defactory dysfunction
 Anatomical complications
 Vaginal shortening
 Injury to adjacent structures (ureters, etc)
Urinary Incontinence
• Stress
• OAB
• Mixed
AUA Guidelines-Incontinence
Summary
• Index patient - The index patient is defined as an
otherwise healthy female patient who has
elected surgical therapy for the correction of SUI
as in the previous guideline.
• Surgical efficacy was defined in three parts:
– 1) the resolution and lack of recurrence of SUI and
urgency;
– 2) the resolution of prolapse and the lack of
recurrence or new onset of prolapse; and
– 3) the incidence and severity of adverse events of
these treatments.
To confirm the diagnosis and characterize SUI - Stress urinary
incontinence may be characterized by the following:
• demonstration of leakage with increasing abdominal pressure (see
below)
• frequency of incontinence episodes (diagnosed by history,
questionnaire, bladder
• diary)
• severity (the volume of urine leakage diagnosed by history,
questionnaire, bladder
• diary, pad test)
• degree of bother (diagnosed by history, bladder diary,
questionnaire)
• sphincter function (diagnosed by examination, Valsalva leak point
pressure, urethral
• pressure profile)
• degree of urethral mobility (diagnosed by estimation at time of
physical examination,
• cotton-swab test, or imaging)
• Standard: The evaluation of the index patient
should include the following components:
• Focused history
• Focused physical examination
• Objective demonstration of SUI
• Assessment of postvoid residual urine volume
• Urinalysis, and culture if indicated
• Recommendation: Elements of the history
should include the following:
– Characterization of incontinence (stress, urge,
etc.)
– Frequency, bother and severity of incontinence
episodes
– Impact of symptoms on lifestyle
– Patient’s expectations of treatment
• Recommendation: Additional diagnostic
studies can be performed to assess the
integrity and function of the lower urinary
tract.
• Pad testing and/or voiding diary
• Urodynamics
• Cystoscopy
• Imaging
Complications of Surgical Treatment
•
•
•
•
•
•
•
•
•
Urinary retention
Perioperative genitourinary
Delayed genitourinary
Gastrointestinal
Vascular
Neurological
Infectious
General medical
Death
• Standard: Patients with urge incontinence
without stress incontinence should not be
offered a surgical procedure for stress
incontinence.
• Recommendation: Synthetic sling surgery is
contraindicated in stress incontinent patients
with a concurrent urethrovaginal fistula,
urethral erosion, intraoperative urethral
injury and/or urethral diverticulum.
• Option: The five major types of procedures
(injectables, laparoscopic suspensions,
midurethral slings, pubovaginal slings and
retropubic suspensions), although not
equivalent, may be considered for the index
patient.
AUA Guidelines-OAB
Summary
Diagnosis:
• The clinician should engage in a diagnostic process to document symptoms and
signs that characterize OAB and exclude other disorders that could be the cause of
the patient’s symptoms; the minimum requirements for this process are a careful
history, physical exam, and urinalysis. Clinical Principle
• In some patients, additional procedures and measures may be necessary to
validate an OAB diagnosis, exclude other disorders and fully inform the treatment
plan. At the clinician’s discretion, a urine culture and/or post-void residual
assessment may be performed and information from bladder diaries and/or
symptom questionnaires may be obtained. Clinical Principle
• Urodynamics, cystoscopy and diagnostic renal and bladder ultrasound should not
be used in the initial workup of the uncomplicated patient. Clinical Principle
• OAB is not a disease; it is a symptom complex that generally is not a lifethreatening condition. After assessment has been performed to exclude conditions
requiring treatment and counseling, no treatment is an acceptable choice made by
some patients and caregivers. Expert Opinion
• Clinicians should provide education to patients regarding normal lower urinary
tract function, what is known about OAB, the benefits vs. risks/burdens of the
available treatment alternatives and the fact that acceptable symptom control may
require trials of multiple therapeutic options before it is achieved. Clinical Principle
AUA Guidelines-OAB
Summary
First-Line Treatments:
• Clinicians should offer behavioral therapies (e.g.,
bladder training, bladder control strategies, pelvic
floor muscle training, fluid management) as first
line therapy to all patients with OAB. Standard
(Evidence Strength Grade B)
• Behavioral therapies may be combined with antimuscarinic therapies. Recommendation (Evidence
Strength Grade C)
AUA Guidelines-OAB
Summary
Second-Line Treatments:
• Clinicians should offer oral anti-muscarinics including darifenacin, fesoterodine, oxybutynin,
solifenacin, tolterodine or trospium (listed in alphabetical order; no hierarchy is implied) as secondline therapy. Standard (Evidence Strength Grade B)
•
If an immediate release (IR) and an extended release (ER) formulation are available, then ER
formulations should preferentially be prescribed over IR formulations because of lower rates of dry
mouth. Standard (Evidence Strength Grade B)
• Transdermal (TDS) oxybutynin [patch (now available to women ages 18 years and older without a
prescription)* or gel] may be offered. Recommendation (Evidence Strength Grade C)
• If a patient experiences inadequate symptom control and/or unacceptable adverse drug events
with one anti- muscarinic medication, then a dose modification or a different anti-muscarinic
medication may be tried. Clinical Principle
• Clinicians should not use anti-muscarinics in patients with narrow-angle glaucoma unless approved
by the treating ophthalmologist and should use anti-muscarinics with extreme caution in patients
with impaired gastric emptying or a history of urinary retention. Clinical Principle
• Clinicians should manage constipation and dry mouth before abandoning effective anti-muscarinic
therapy. Management may include bowel management, fluid management, dose modification or
alternative anti- muscarinics. Clinical Principle
• Clinicians must use caution in prescribing anti-muscarinics in patients who are using other
medications with anti- cholinergic properties. Expert Opinion
• Clinicians should use caution in prescribing anti-muscarinics in the frail OAB patient. Clinical
Principle
Patients who are refractory to behavioral and medical therapy should be evaluated by an
appropriate specialist if
• they desire additional therapy. Expert Opinion
AUA Guidelines-OAB
Summary
Third-line Treatments:
• . Clinicians may offer sacral neuromodulation (SNS) as third line treatment in a carefully selected
patient population characterized by severe refractory OAB symptoms or patients who are not
candidates for second-line therapy and are willing to undergo a surgical procedure.
Recommendation (Evidence Strength – Grade C)
• Clinicians may offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully
selected patient population. Option (Evidence Strength Grade C)
•
Clinicians may offer intradetrusor onabotulinum toxin A as third-line treatment in the carefullyselected and thoroughly-counseled patient who has been refractory to first- and second-line OAB
treatments. The patient must be able and willing to return for frequent post-void residual
evaluation and able and willing to perform self- catheterization if necessary. Option (Evidence
Strength Grade C)
• Additional Treatments:
•
Indwelling catheters (including transurethral, suprapubic, etc.) are not recommended as a
management strategy for OAB because of the adverse risk/benefit balance except as a last resort in
selected patients. Expert Opinion
•
In rare cases, augmentation cystoplasty or urinary diversion for severe, refractory, complicated
OAB patients may be considered. Expert Opinion
• Follow-Up:
•
The clinician should offer follow up with the patient to assess compliance, efficacy, side effects and
possible alternative treatments. Expert Opinion
Basic Assessment
History
Frequency/Volume Chart
Post-void residual
Physical examination
Urinalysis, culture
Cytology if smoking hx
Symptom questionnaire
Pain evaluation
First-Line Treatments
General Relaxation/Stress Management
Pain Management
Patient Education
Self-care/Behavioral Modification
The evidence supporting the use of Neuromodulation, Cyclosporine A, and BTX for IC/BPS is limited by many factors including study quality, small sample sizes, and lack of durable follow up.
None of these therapies have been approved by the U.S. Food and Drug Administration for this
indication. The panel believes that none of these interventions can be recommended for generalized use for this disorder, but rather should be limited to practitioners with experience managing
this syndrome and willingness to provide long term care of these patients post intervention.
Dx Urinary
Tract Infection
Signs/Symptoms of
Complicated IC/BPS
TREAT &
REASSESS
Incontinence/OAB
GI signs/symptoms
Microscopic/gross hematuria/sterile pyuria
Gynecologic signs/symptoms
Research Trials
Patient enrollment as
appropriate at any point
in treatment process
Copyright © 2010 American Urological Association Education and Research, Inc.®
Fourth-Line Treatments
Neuromodulation
Pain Management
NORMAL
ABNORMAL
TREAT AS INDICATED
Sixth-Line Treatments
Diversion w/ or w/out cystectomy
Pain Management
Substitution cystoplasty
NOTE: For patients with endstage structurally small bladders,
diversion is indicated at any time
clinician and patient believe appropriate
Fifth-Line Treatments
Cyclosporine A
Intradetrusor BTX
Pain Management
Interstitial Cystitis
Clinical Management Principles
- Treatments are ordered from most to least conservative; surgical treatment is appropriate only after other
treatment options have been found to be ineffectiveo
(except fr treatment of Hunner’s lesions if detected)
- Initial treatment level depends on symptom severity,
clinician judgment, and patient preferences
- Multiple, simultaneous treatments may be considered
if in best interests of patient
- Ineffective treatments should be stopped
- Pain management should be considered throughout
course of therapy with goal of maximizing function
and minimizing pain and side effects
- Diagnosis should be reconsidered if no improvement
w/in clinically-meaningful time-frame
Third-Line Treatments
Cystoscopy under anesthesia
w/ hydrodistension
Pain Management
Tx of Hunner’s lesions if found
Consider:
- Urine cytology
- Imaging
- Cystoscopy
- Urodynamics
- Laparoscopy
- Specialist referral
(urologic or nonurologic as appropriate)
Treatment Algorithm
Second-Line Treatments
Appropriate manual physical therapy techniques
Oral: amitriptyline, cimetidine, hydroxyzine, PPS
Intravesical: DMSO, heparin, Lidocaine
Pain Management
American Urological Association
IC/BPS: An unpleasant sensation (pain, pressure,
discomfort) perceived to be related to the urinary
bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes
FEMALE UROLOGY QUESTIONS
Q #1
• The majority of sympathetic innervation of the
LUT comes from:
a.
b.
c.
d.
e.
Pelvic plexus
Hypogastric nerve
Pudendal nerve
Onuf’s nerve
Alcok’s plexus
• A 75-year-old woman has recurrent
cystitis. Physical examination demonstrates a
grade I cystocele and atrophic vaginitis. A
postvoid residual is 45 cc. IVP and VCUG are
normal. The best management is:
a. Vaginal pessary.
b. Oral estrogen.
c. Intravaginal estrogen.
d. Cranberry juice.
e. Prophylactic antibiotic.
• A 32-year-old woman complains of a
malodorous fishy vaginal discharge. She has a
single male partner and uses an intrauterine
device for contraception. The next step is:
a. Remove the intrauterine device.
b. Metronidazole for the patient.
c. Metronidazole for the patient and her
partner.
d. Ciprofloxacin for the patient.
e. Ciprofloxacin for the patient and her
partner.
• A 45-year-old woman reports eight urinary
tract infections in the past year, all of which
are associated with lower tract urinary tract
symptoms only. Which of the following is
most likely to be a risk factor:
a. Tampon use
b. Parity
c. Douching
d. Daily bicycle riding
e. Spermicide use
• Bacteriuria associated with pregnancy is
diagnosed most frequently:
a. In the first trimester
b. In the second trimester
c. In the third trimester
d. Immediately postpartum
e. Equally throughout pregnancy
• A 36-year-old woman has suffered from recurrent
cystitis from several years. An IVP was normal two
years ago. Now, she is treated with trimethoprim-sulfa
while a urine culture is pending. The culture
demonstrates Proteus mirabilis, sensitive to ampicillin,
but not to trimethoprim or sulfa. She is treated for
eight days with ampicillin 250 mg QID. A catheterized
urine culture obtained 10 days after the ampicillin is
discontinued again demonstrates Proteus mirabilis
sensitive to ampicillin and cephalexin. The next step
is:
a. Restart ampicillin for 4-6 weeks
b. Restart ampicillin for 10 days
c. Begin cephalexin for 10 days
d. Obtain an IVP
e. Introital culture
• A 42-year-old woman with poor controlled
diabetes has a residual urine of 200 cc. She
has had one episode of cystitis and currently
has no voiding symptoms. The best way to
prevent recurrent bacterial urinary tract
infections is:
a. Tight control of the diabetes.
b. Clean intermittent catheterization.
c. Oral estrogen
d. Avoid bladder intrumentation.
e. Suppressive antiobiotic therapy.
• Estrogen is effective in controlling lower
urinary tract infections in postmenopausal
women by:
a. Decreasing vaginal pH.
b. Decreasing bacterial adherence.
c. Altering the fecal reservoir of bacteria.
d. Increasing antibody production.
e. Increasing antibiotic perfusion into the
vagina.
• A 45-year-old woman has dysuria and a thin
white vaginal discharge. Urinalysis is
normal. Vaginal pH is 6.0. The application of
potassium hydroxide to the discharge results
in a fishy odor. Treatment is:
a. Fluconazole
b. Doxycycline
c. Acyclovir
d. Metronidazole
e. Ciprofloxacin
• The first event to occur with normal
micturition is
a. Relaxation of the prostate and prostatic
capsule
b. Opening of the bladder neck
c. Relaxation of external striated sphincter
d. Contraction of the bladder body
e. Contraction of the bladder base
• A 74-year-old woman has symptomatic stress
incontinence and detrusor instability, but
would like to avoid surgery. The best
pharmacologic approach is
a. Oxybutynin
b. Tolterodine
c. Imipramine
d. Terazosin
e. Ephedrine
• A 64-year-old woman underwent a MarshallMarchetti-Krantz urethropexy five years ago and
a transvaginal urethropexy one year ago, but still
has severe urinary incontinence. She leaks with
coughing and sneezing, and also without any
physical activity. She denies urge
incontinence. The best diagnostic test is
a. Urethral pressure profile
b. Video-urodynamics
c. Cystometry
d. VCUG
e. CMG-EMG
• A 60-year-old woman develops vaginal leakage of
urine and is found to have an ureterovaginal
fistula five days after an abdominal
hysterectomy. A retrograde ureterogram
demonstrates a fistula 2-3 cm above the
bladder. Attempts at retrograde and antegrade
passage of a ureteral stent are unsuccessful. The
most appropriate management is
a. Observation
b. Ureteroneocystostomy
c. Ureteroureterostomy
d. Percutaneous nephrostomy
e. Bladder flap ureterovesicoplasty
• A 24 year old woman presents with vaginal pain,
dysuria, and a clear vaginal discharge. A cervical
swab for a polymerase/ligand chain reaction test
is positive and culture grows C.
trachomatis. What is the diagnosis and
treatment?
a. Chlamydia, Ceftriaxone 125mg IM
b. Chlamydia, Azithromycin 1gm PO
c. Gonorrhea, Ceftriaxone 125mg IM plus
Azithromycin 1gm PO
d. Gonorrhea, Cipro 500mg PO plus Doxyclycline
100mg PO BID x 7 days
e. Chlamydia, Cipro 500mg PO
• An 84-year-old woman, with mild cognitive
impairment, has urge incontinence. She has a
grade I cystocele, residual urine of 50 cc, and a
normal urinalysis. Her incontinence should
initially be treated by
a. Oxybutynin
b. Fluid restriction
c. Imipramine
d. Kegel exercise
e. Prompted voiding
• A 24 year old woman presents with vaginal pain,
dysuria, and a grayish-white vaginal discharge. A
KOH test is positive and clue cells are detected in
the vaginal discharge. What is the diagnosis and
treatment?
a. Gardnerella vaginalis, Metronidazole 500mg PO
BID x 7 days
b. Chlamydia, Azithromycin 1gm PO
c. Trichomonas, Metronidazole 2gm PO
d. Candidiasis, Clotriamazole vaginal cream x 7
days
e. Herpes Simplex, Acyclovir 400mg PO TID x 10
days
• A 50-year-old woman has urinary frequency,
occasional urge incontinence, and
dyspareunia. She has a history of recurrent
urinary tract infections. On physical examination,
the bladder is not distended, but the urethra is
tender to palpation. Which of the following
would most reliably establish a definitive
diagnosis: a. IVP with postvoid film
b. Urethral calibration with residual urine
assessment
c. Pelvic MRI scan
d. Cystoscopy
e. Urodynamics
• A 58-year-old woman complains of severe
urinary incontinence with coughing or
sneezing. Her abdominal leak point pressure
is 30 cm H2O with urethral hypermobility, and
there is no evidence of detrusor instability on
CMG. The best management is
a. Endoscopic needle suspension
b. Pubovaginal sling
c. Retropubic suspension
d. Artificial urinary sphincter
e. Periurethral collagen injection
• A 24 year old woman presents with a frothy,
green vaginal discharge and a strawberry red
appearing vulva and cervix. What is the
diagnosis and treatment?
a. Gardnerella vaginalis, Metronidazole 500mg
PO BID x 7 days
b. Chlamydia, Azithromycin 1gm PO
c. Trichomonas, Metronidazole 2gm PO
d. Candidiasis, Diflucan 150mg PO
e. Herpes Simplex, Acylovir 400mg PO TID x 10
days
• The most important factor for successful
vesicovaginal fistula repair using an omental
interposition graft is
a. The length of the omentum
b. Adequate mobilization of the gastroepiploic
vascular pedicle
c. Adequate mobilization of the omentum by
splenectomy
d. Ligation of the short gastric vessels
e. Vaginal closure using non-absorbable suture
material
• A 24 year old woman presents with vaginal
itching, and a cheesy, white vaginal discharge;
a KOH prep demonstrates hyphae. What is
the diagnosis and treatment?
a. Gardnerella vaginalis, Metronidazole 500mg
PO BID x 7 days
b. Chlamydia, Azithromycin 1gm PO
c. Trichomonas, Metronidazole 2gm PO
d. Candidiasis, Diflucan 150mg PO
e. Herpes Simplex, Acyclovir 400mg PO TID x
10 days
• A 65 year old woman presents with itching of the
perineum and external discomfort when
voiding. On examination she is noted to have
multiple flat-topped, violaceous papules on the
inner aspect of the labia majora. A biopsy reveals
the pathology demonstrated below. How should
she be treated?
a. Surgical excision
b. Radiation therapy
c. Laser therapy
d. Doxycycline 100 mg BID for 7 days
e. Topical steroids
• A 70 year woman has noted an itchy and
painful lesion of her right labia majora. On
examination she has a sharply demarcated
erythematous plaque on the external aspect
of the right labia majora. Biopsy reveals the
pathology below. What is the
diagnosis?
a. Bowenoid papulosis
b. Lichen sclerosis et atrophicus
c. Lichen planus
d. Squamous cell carcinoma
e. Condyloma acuminatum
• Central cystoceles result from:
a. detachment of the paravaginal support from
the arcus tendineus fasciae
b. breakage of the pubourethral ligaments
c. separation of the pubocervical fascia from the
pubis
d. widening of the urogenital hiatus
e. weakness of the anerior vaginal wall or fascia
• A successful rectocele repair may accomplish
all of the following, except:
a. Narrowing of the posterior aspect of the
vaginal canal
b. Plication of the prerectal and pararectal
fascias
c. Prevention of recurrent incontinence after
anterior suspension
d. Narrowing of the vaginal caliber
e. Narrowing of the posterior aspect of the
levator (urogenital) hiatus with levator
• All of the following may be indications for
retropubic repair of stress incontinence
except:
a. a concomitant hysterectomy requiring an
abdominal approach
b. stress urinary incontinence (type II) in a
patient with COPD
c. genuine SUI and a lateral defect cystocele
d. intrinsic sphincter dysfunction SUI
e. documented urethral descent and SUI with
straining
• A compressive, as opposed to a previously
supportive sling, is most indicated in which of
the following situations?
a. Urethral hypermobility and enterocele
b. VLPP >90 cm H2O and urethral
hypermobility
c. VLPP <60 cm H2O and minimal urethral
mobility
d. High grade vaginal prolapse with occult SUI
e. VLPP = 60 cm H2O and positive Q-tip test
• Synthetic sling material, as opposed to
autologous and allograft fascia, is associated
with:
a. a higher incidence of erosion and infection
b. a greater chance of disease transmission
c. lower cost
d. a greater ease of tension adjustment
e. a superior success rate over time
• What factor most influences the positive
results of treatment with injectables for
ISD SUI?
a. bladder capacity
b. viability of tissue at the injection site
c. the type of injectable material used
d. volume of the injectable agent used
e. leak point pressure
• Which of the following represents the most
definitive management technique
for
vesicovaginal fistulas?
a. prolonged urethral catheter drainage with oral
anticholinergic paralysis of the bladder b. cystoscopic electrofulguration of the fistula site
followed by 2 weeks of catheter drainage
c. tension-free, nonoverlapping closure of vaginal
and vesical components with interposition of
viable tissue
d. colpocleisis
e. a modified Latzko technique with overlapping
suture lines
• All of the following modalities may assist in
the diagnosis of urethral diverticulum except
which one?
a. MRI of the periurethral tissues
b. transvaginal or endoluminal urethral U/S
c. cystoscopy
d. voiding cystourethrography with or without
the double balloon technique
e. intravenous pyelogram
• The voiding diary completed by an 83-year-old
woman bothered by daytime incontinence
discloses 800 cc output between 8:00 am and
11:00 pm and
1500 cc from 11:00 pm to 8:00
am. What should the next step be?
a. Have her repeat the diary with a record of fluid
intake.
b. Prescribe furosemide at 7:00 pm to reduce
nocturnal excretion.
c. Have her use pressure gradient stockings to
minimize peripheral edema.
d. All of the above.
e. None of the above.
• A 54-year-old woman, who underwent radiation
therapy for cervical cancer two years ago, has
microhematuria. Transurethral resection of a
lesion 2 cm above the left ureteral orifice reveals
an inverted papilloma. Three days
postoperatively, she develops a vesicovaginal
fistula. The best treatment is
a. Immediate transvaginal repair
b. Transvaginal repair in six months
c. Immediate transabdominal repair
d. Transabdominal repair in six months
e. Urinary diversion
• The total urinary incontinence after vaginal
hysterectomy is most likely due to
a. intrinsic sphincter deficiency
b. urethral hypermobility
c. vesicovaginal fistula
d. detrusor instability
e. urethrovaginal fistula
• A 74-year-old woman has symptomatic stress
incontinence and detrusor instability, but
would like to avoid surgery. The best
pharmacologic approach is
a. oxybutynin
b. topical estrogen
c. imipramine
d. phenylpropanolamine
e. desmopressin
• The abdominal leak point pressure is the same
as the:
a. valsalva leak point pressure
b. bladder leak point pressure
c. detrusor leak point pressure
d. cystometric capacity
e. change in pressure divided by change in
volume
• A 62-year-old woman complains of urge
incontinence and difficulty initiating volutional
urination 12 months after a needle suspension
operation for stress incontinence. Her residual
urine is 120 ml, and mid-voiding pressure is 52
cm/H2O during an uninhibited contraction. A
resting cystogram is shown in the figure
below. The best method of management is:
a. clean intermittent catheterization
b. oxybutynin and timed voiding
c. hyperdilation of the urethra
d. removal of one suspension suture
e. transvaginal urethrolysis and cystocele repair
• Female urinary incontinence occurring only
during intercourse is best managed by:
a. behavioral therapy
b. bladder neck suspension
c. ephedrine
d. oxybutynin
e. collagen injection
• During secondary repair of a high
vesicovaginal fistula, a Martius flap is
harvested, but is of insufficient length to reach
the fistula site. The next step is use of:
a. myocutaneous gracilis flap
b. gluteal flap
c. omentum
d. peritoneal flap
e. myocutaenous labial flap
• Which medication is contraindicated in
managing incontinence in the asthmatic
patient?
a. ephedrine
b. Sudafed
c. propranolol
d. phenylephrine
e. amphetamine
• Urinary incontinence –
a. does not matter to children with spinal cord
problems
b. procedures may put the upper tracts at risk
for deterioration
c. means never having to do another CMG
d. procedures are more successful in males
with spina bifida than females
e. none of the above
• A 50-year-old woman is incontinent of urine. She
leaks almost continuously when in an upright
position. Five years ago, she underwent an
anterior repair, and one year ago a MarshallMarchetti procedure. CMG demonstrates good
bladder compliance without uninhibited
contractions. An upright cystogram shows an
open bladder neck. The operative procedure of
choice is:
a. anterior bladder neck reconstruction
b. Burch colposuspension
c. posterior bladder neck reconstruction
d. pubovaginal sling procedure
e. needle suspension procedure
• The intended effect of bladder neck suspension
procedures is:
a. provide increase closure pressure of the
urethral sphincter
b. raise the urethra into a high retropubic position
where intra-abdominal pressures may
be transmitted to the urethral sphincter
c. re-establish the urethrovesical angle to 90o
d. provide a well supported back board on which
the urethra can be compressed during coughing
and straining
e. stabilize detrusor function
• Voiding occurs via a detrusor contraction
which pulls open the bladder outlet and
urethra.
a. true
b. false
• A 65-year-old woman complains of
incontinence when she runs water in the sink
or tub. A CMG is normal except for urgency at
a volume of 255 ml. The next step in
management is:
a. cystoscopy and cytology
b. video urodynamics
c. biofeedback and electrical stimulation
d. pelvic floor exercises
e. Anticholinergics and timed voiding
• A 68-year-old woman complains of urge incontinence,
which requires three pads per day. She usually voids
about every two hours during the day and has nocturia
twice per night. Examination with a full bladder during
cough reveals a grade 2 cystourethrocele and mild
stress incontinence. A CMG reveals a stable bladder
with a capacity of 250 cc. She voids to completion with
a maximum flow rate of 26 ml/sec. She desires
treatment. The most reasonable treatment is:
a. oxybutynin
b. cystogram
c. video urodynamics
d. urethropexy
e. ambulatory urodynamics
• Which type of neurogenic bladder usually
implies adequate emptying?
a. sensory
b. motor
c. uninhibited
d. reflex
e. autonomous
• This 37 year old woman has developed postvoid dribbling and irritative
bladder symptoms. The plain film of the
abdomen is negative. What does this
cystogram study demonstrate? a. vesicovaginal fistula
b. urethral diverticulum
c. ectopic ureterocele
d. bladder tumor
e. none of the above
• An 83 year old woman with nocturnal enuresis
is treated with DDAVP (desmopressin). After
ten days of treatment she becomes mentally
confused and subsequently has a seizure. The
next best step is?
a. serum desmospressin level
b. serum potassium
c. serum sodium
d. head CT scan
e. lumbar puncture
• Central cystoceles result from:
a. detachment of the paravaginal support from
the arcus tendineus fasciae
b. breakage of the pubourethral ligaments
c. separation of the pubocervical fascia from
the pubis
d. widening of the urogenital hiatus
e. weakness of the anterior vaginal wall or
fascia
• Which of the following statements best
describes a successful rectocele repair?
a. Widens the posterior aspect of the vaginal
canal
b. Involves plication of the prerectal and
pararectal fascias
c. Prevents recurrent incontinence after
anterior suspension
d. Shortens the vagina
e. Opens the posterior aspect of the levator
(urogenital) hiatus with levator plication
• Which of the following is not an indication for
retropubic repair of stress incontinence (i.e.,
Burch procedure)?
a. a concomitant hysterectomy requiring an
abdominal approach
b. stress urinary incontinence (type II) in a
patient with an ovarian cyst
c. genuine SUI and a lateral defect cystocele
d. intrinsic sphincter dysfunction SUI
e. documented urethral descent and SUI with
straining
• A compressive, as opposed to a previously
supportive sling, is most indicated in which of
the following situations?
a. Urethral hypermobility and enterocele
b. VLPP >90 cm H2O and urethral
hypermobility
c. VLPP <60 cm H2O and minimal urethral
mobility
d. High grade vaginal prolapse with occult SUI
e. VLPP = 60 cm H2O and positive Q-tip test
• Synthetic sling material, as opposed to
autologous and allograft fascia, is associated
with:
a. a higher incidence of erosion and infection
b. a greater chance of disease transmission
c. lower cost
d. a greater ease of tension adjustment
e. a superior success rate over time
• What factor most influences the positive
results of treatment with injectables for ISD
SUI?
a. bladder capacity
b. viability of tissue at the injection site
c. the type of injectable material used
d. volume of the injectable agent used
e. leak point pressure
• Which of the following represents the most
definitive management technique
for
vesicovaginal fistulae?
a. prolonged urethral catheter drainage with oral
anticholinergic paralysis of the bladder
b. cystoscopic electrofulguration of the fistula site
followed by 2 weeks of catheter drainage
c. tension-free, non-overlapping closure of vaginal
and vesical components with interposition of viable
tissue
d. colpocleisis
e. a modified Latzko technique with overlapping
suture lines
• All of the following modalities may assist in
the diagnosis of urethral diverticulum except
which one?
a. MRI of the periurethral tissues
b. transvaginal or endoluminal urethral U/S
c. cystoscopy
d. voiding cystourethrography with or without
the double balloon technique
e. intravenous pyelogram
• A 55-year-old multi-parous woman has
urge
incontinence. Urinalysis is normal and
physical
exam demonstrates a Grade 3 cystocele.
Urodynamics
reveal a PVR of 100 cc,
involuntary
bladder contractions with incontinence,
and a
detrusor pressure at maximum flow
(8mL/sec)
of 50 cmH2O.When the cystocele is
reduced,
no stress urinary incontinence can be
elicited.
The next step is:
a. Oxybutynin
b. Doxazosin
c. Pubovaginal sling
d. Anterior colporrhaphy
e. Pubovaginal sling and anterior colporrhaphy
• A 61-year-old woman becomes
incontinent
immediately after a transvaginal
repair of
Grade III cystocele. This is most likely
due to:
a. Detrusor instability
b. Partial bladder denervation
c. Underlying urethral deficiency
d. Surgical damage to the urethral sphincter
e. Bladder neck and proximal
urethral
obstruction
• A 55-year-old woman underwent
amidurethral
sling for stress incontinence
5months ago. She
now has dysuria, urgency and
frequency,
despite antibiotic treatment for 2
documented
UTIs. Urinalysis reveals 2–3
RBC/hpf. Pelvic
US reveals a 50 cc PVR. The next
step is:
a. IVP
b. Uroflowmetry
c. Filling cystometry
d. VCUG
e. Cystoscopy
• 3 weeks after an MMK, a 40-year-old
woman
develops pelvic and suprapubic pain
and a fever
of 101°F. She experiences
difficulty adducting
her thighs and has pain to
palpation on pubis.
The most likely diagnosis
is:
a. Osteitis pubis
b. Osteomyelitis pubis
c. Obturator nerve injury
d. Urinary extravasation
e. Pelvic abscess
• A 62-year-old woman complains of UI and
difficulty
initiating voiding 12months after a
needle
suspension for SUI. Her PVR is
120mLand
mid-voiding pressure is 52 cmH2O
during an
uninhibited contraction. The best
treatment is:
a. CIC
b. Ditropan and timed voiding
c. Urethral dilation
d. Removal of suspension suture
e. Transvaginal urethrolysis
• A 74-year-old female with SUI and DI
would
like to avoid surgery. The best
pharmacologic
approach is:
a. Ditropan
b. Detrol
c. Imipramine
d. Terazosin
e. Ephedrine
• A 75-year-old woman has recurrent cystitis.
PE
demonstrates Grade I cystocele and
atrophic
vaginitis. PVR 45 cc IVP and VCUG
are normal.
The best management is:
a.Vaginal pessary
b. Oral estrogen
c. Intravaginal estrogen
d. Prophylactic antibiotics
• A 54-year-old woman S/PXRT for cervical
cancer
2 years ago develops micro hematuria.
TUR
of a lesion 2 cm above the LUO reveals
an
inverted papilloma. 3 days postop, she
develops
a vesicovaginal fistula. The best
treatment is:
a. Immediate transvaginal repair
b. Transvaginal repair in 6months
c. Immediate transabdominal repair
d. Transabdominal repair in 6months
e. Urinary diversion
• A 64-year-old female S/PMMK 5 years
ago,
and transvaginal needle suspension 1
year ago
still has severe urinary incontinence.
She leaks
with and without physical activity.
The best
diagnostic test is:
a. Urethral pressure profile
b. Video urodynamics
c. Cystometry
d. VCUG
e. CMG EMG
• A 64-year-old woman has a Grade
IVcystocele
without urinary incontinence. To
determine if
she needs a concomitant antiincontinence
surgery with the cystocele
repair, she should
undergo:
a. PelvicMRI
b. Urethral pressure profilometry
c. Urodynamics with a pessary
d. Cysto
e. Uroflow with PVR
• 37 y G3P3 presents with co of constipation, and
the feeling of something gettign stuck. She
occasionally uses perineal decompression to
complete a bowel movement. POP reveals Aa0,
Ba0, C-3, Gh3, Pb4, TVL 9, Ap0, Bp0, D-5. Multiple
fiber regimens have not been successful and she
is desperate for a surgical repair. The appropriate
next step is:
a. Urodynamics, followed by TVH AP repair
b. Posterior repair
c. Trial of Laxatives
d. Further evaluation of constipation-colon Transit
study
• A 42 yo woman presents with co of leaking urine daily.
She states she voids every 1-2 hours, which is an
increase in frequency for her. She reports most urges to
void are sudden, very strong and cannot be deferred
often resulting in incontinence episodes. In addition,
she will leak with any cough or sneeze and has quit
playing tennis because of the staining of her clothing
with urine. She gets up to vid at least once every night
but can not go back to sleep afterwards. What is her
diagnosis?
a.
b.
c.
d.
e.
Urinary incontinence, OAB
Mixed incontinence, OAB
Urge incontinence, OAB
Detrusor overactivity, genuine SUI, urinary frequency
Stress incontinence.
I.C. PAINFUL BLADDER SYNDROME
Thank you
&
Good Luck
Female Urology
Firouz Daneshgari, M.D.