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UROGYNECOLOGY

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BACKGROUND

RECURRENT UTI

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  • Defined as 2 UTIs in 6 months or 3 in 12 months
  • Need to be culture proven
  • Only need treatment if asymptomatic EXCEPT in the case of pregnancy
  • Evidence based treatments for prevention include:
    • Drinking at least 1.5 Litres of water per day (JAMA)
    • Cranberry capsules (not juice)
    • D-Mannose
    • Vaginal hormone
    • +/- prophylactic antibiotics

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BACKGROUND

PELVIC ORGAN PROLAPSE

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  • Descent of one or more of the bladder, cervix/uterus, vault, small bowel or rectum into the vaginal tissues
  • May cause a bulge outside of the body
  • Generally bothersome when stage 2 and beyond

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BACKGROUND

PELVIC ORGAN PROLAPSE

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  • Treatment options range from expectant to pelvic floor physiotherapy to pessary device, to surgery

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BACKGROUND

URINARY INCONTINENCE

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  • Differential diagnosis: stress urinary incontinence, urge urinary incontinence, overflow incontinence
  • Having an active urinary tract infection can worsen this symptom
  • Each cause is ruled out and ruled in:
    • overflow incontinence is rule out with ___________________________________
    • stress incontinence is ruled in with ______________________________________
    • stress urinary incontinence is ruled out with______________________________
    • urge urinary incontinence is ruled in with _________________________________
    • urge urinary incontinence is ruled out with ________________________________

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BACKGROUND

URINARY INCONTINENCE

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  • Management options depend on the cause
  • Overflow: intermittent self-catheterization
  • Stress: Weight loss, dietary changes, pelvic physiotherapy, pessary, surgery (bulking or sling)
  • Urge: Weight loss, dietary changes, bladder retraining, pelvic physiotherapy, pessary (if prolapse concomitant), medications (anticholinergic therapy, B3 agonist therapy), bladder botox, sacral nerve stimulation

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BACKGROUND

FECAL INCONTINENCE

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  • Differential diagnosis: rectovaginal fistula, sphincter malfunction (previous OASIS), bowel disease (IBD, infectious case, etc), overflow incontinence (constipation)
  • Common cause: injury to external and/or internal anal sphincter during labour/delivery
  • Higher risk with instrumented delivery
  • Post-menopause fecal incontinence is unmasked due to muscle tone decreasing (can no longer compensate)
  • Differentiate incontinence of stool: soft stool only? Hard stool only? Gas?
  • Investigation: physical examination “pill rolling technique”, endoanal ultrasound, anal manometry
  • Management depends on cause diet changes (FIBER 25-35g per day, H20), medication (ie. loperamide), pelvic physiotherapy, sacral nerve stimulation
  • Surgery rarely indicated (ie. delayed sphincteroplasty)

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COMMON THEME IN PELVIC FLOOR DISORDERS | PREGNANCY & DELIVERY

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PREVENTION IS PARAMOUNT

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COMMON THEME IN PELVIC FLOOR DISORDERS | PREGNANCY & DELIVERY

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SOGC, 2015

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CASE

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  • 81 Year-old woman
  • Gravidity: 5
  • Para: 4
  • Presents to outpatient GYN clinic with concerns of recurrent UTI, pelvic organ prolapse, urinary incontinence and fecal incontinence

What do you want to know on history?

  • Bladder
  • Bowel
  • Prolapse
  • Sexual Function
  • Medical History
  • Surgical History
  • Obstetrical History
  • Medications
  • Allergies
  • Family History
  • Social History

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CASE

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  • 81 Year-old woman
  • Gravidity: 5
  • Para: 4
  • Presents to outpatient GYN clinic with concerns of recurrent UTI, pelvic organ prolapse, urinary incontinence and fecal incontinence

What do you want to know on exam?

ABDOMEN

PELVIS

PERIPHERY

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CASE

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  • 81 Year-old woman
  • Gravidity: 5
  • Para: 4
  • Presents to outpatient GYN clinic with concerns of recurrent UTI, pelvic organ prolapse, urinary incontinence and fecal incontinence

What investigations should you order?

IMAGING

LABS

OTHER

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CASE

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  • 81 Year-old woman
  • Gravidity: 5
  • Para: 4
  • Presents to outpatient GYN clinic with concerns of recurrent UTI, pelvic organ prolapse, urinary incontinence and fecal incontinence

How should you manage all patients with pelvic floor disorders?

Vaginal Hormone

Pelvic Physiotherapy

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CASE

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  • 81 Year-old woman
  • Gravidity: 5
  • Para: 4
  • Presents to outpatient GYN clinic with concerns of recurrent UTI, pelvic organ prolapse, urinary incontinence and fecal incontinence

How do you manage the following patient concerns?

Recurrent UTIs

Pelvic Organ Prolapse

Urinary Incontinence

Fecal Incontinence

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RESOURCES & REFERENCES

Interested in learning more? Check out these articles!

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www.yourpelvicfloor.org/leaflets

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FREE medical student membership:

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www.canadiansocietyforpelvicmedicine.org

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AUTHOR(S)

Dr May Sanaee

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