Why does ligation of the hypogastric (internal iliac) artery effectively control intractable pelvic hemorrhage?
Answer(s): C
Bilateral hypogastric artery ligation converts the arterial system into a venous system; thereby, reducing the pulse pressure by as much as 85%. Subsequent menstrual function and fertility are normal, in part because of the rich collateral circulation to the uterus. The procedure is successful in approximately 50% of cases. The procedure is not technically easy to perform, and an intimate knowledge of the local anatomy is essential to prevent injury to the hypogastric vein or ureter. Uterine hemorrhage not controlled by other means requires a hysterectomy
A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.Which of the following is the most likely diagnosis?
Answer(s): E
Two clues to the diagnosis of detrusor dyssynergia are loss of urine in the recumbent position and inability to stop the urine loss once the stream has begun. Generally, large volumes of urine are lost because of the inability to stop the flow of urine. With GSI, urine is lost only in the upright position when intra-abdominal and intravesical pressure exceeds urethral closing pressure, such as with coughing. Women with SI are able to stop the flow of urine voluntarily and, therefore, the volume of urine lost is small. With GSI, urine loss with coughing is immediate. Women with a vesicovaginal or urethrovaginal fistula will complain of a watery vaginal discharge. Women with an atonic bladder typically void small amounts and complain that the bladder still feels full (which it is). This is a disorder seen in women with neurologic dysfunction of the bladder, such as multiple sclerosis and diabetic neuropathy.
A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.Which of the following would most likely confirm the cause of this woman's incontinence?
Answer(s): D
Although a urine culture is a standard part of the evaluation of women with loss of urine, this woman's history is not consistent with acute cystitis. AQ-tip test is done to assess the angle the urethra makes with the horizontal in the relaxed and voiding circumstances. Though intended to differentiate GSI from other causes of incontinence, it has not proved to be sufficiently sensitive to make this distinction reliably.Urethroscopy is appropriate if a urethrovaginal fistula or urethral diverticulum is suspected.Urethrocystometry is one name for a test that measures the pressure-volume relationship in the bladder. It should be done in most women with incontinence as the most sensitive test to distinguish the various causes of incontinence. An IVP is of little value in determining the cause of incontinence.
A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.Which of the following is the treatment of choice for this woman's urinary incontinence?
Antibiotics are useful only when there is evidence of cystitis. SSRIs are antidepressants that have not been shown to improve incontinence with detrusor dyssynergia. Surgery is of no value and may actually worsen incontinence in women with detrusor dyssynergia. Bladder retraining, in which the patient embarks on a programmed progressive lengthening of the interval of voiding, forms the basis of therapy. While such retraining is occurring, the use of anticholinergic drugs, such as oxybutynin chloride (Ditropan), propantheline (Pro-Banthine), or flavoxate (Urispas), seems to improve the results over use of any one alone.
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