CUC cheat sheet

The levator ani comprises the pubococcygeus, puborectalis, and iliococcygeus; it is innervated by direct branches of the pudendal nerve and the levator ani nerve (S3-S5).

The arcus tendineus levator ani is the lateral attachment of the levator ani along the obturator internus fascia; the arcus tendineus fascia pelvis is the lateral attachment of the paravaginal endopelvic fascia.

The puborectalis sling maintains the anorectal angle (~90 degrees at rest), contributing to fecal continence.

The urethra is supported by the pubourethral ligaments, urethropelvic ligament, and periurethral endopelvic fascia; loss of this support underlies stress incontinence.

DeLancey levels: Level I (cardinal-uterosacral) suspends the uterus/vaginal apex; Level II (paravaginal/arcus tendineus) attaches mid-vagina laterally; Level III (perineal membrane) supports distal vagina.

Internal anal sphincter is smooth muscle (involuntary, resting tone); external anal sphincter is striated (voluntary, squeeze).

The pudendal nerve (S2-S4) provides somatic sensation to the vulva and perineum and motor supply to the external anal and urethral sphincters.

Bladder filling is a sympathetic (T10-L2, beta-3 mediated detrusor relaxation, alpha-1 mediated internal sphincter contraction) process; voiding is parasympathetic (S2-S4) with detrusor contraction and sphincter relaxation.

Postvoid residual can be measured by bladder scan or catheterization; a PVR >150 mL suggests incomplete emptying (thresholds vary by source).

Urodynamic stress incontinence is demonstrated by involuntary urine leakage with increased abdominal pressure during filling cystometry in the absence of detrusor contraction.

Detrusor overactivity is defined as involuntary detrusor contractions during filling; it may be phasic or terminal.

Valsalva leak point pressure (VLPP) <60 cm H2O suggests intrinsic sphincter deficiency; >90 cm H2O suggests urethral hypermobility.

POP-Q staging: Stage 0 = no prolapse; Stage I = leading edge >-1 cm; Stage II = -1 to +1 cm; Stage III = >+1 cm but not complete; Stage IV = complete eversion.

A 24-hour or 3-day bladder diary quantifies fluid intake, voiding frequency, and leakage episodes.

Cotton swab (Q-tip) test: resting angle >30 degrees or straining excursion >30 degrees suggests urethral hypermobility.

Cough stress test: direct visualization of urine loss from the external meatus with cough confirms stress incontinence.

POP-Q points: Aa and Ba (anterior), Ap and Bp (posterior), C (cervix or vaginal cuff), D (posterior fornix), gh (genital hiatus), pb (perineal body), tvl (total vaginal length).

Stage II prolapse is defined by a leading edge between -1 cm and +1 cm relative to the hymen.

Anterior compartment prolapse (cystocele) is the most common form of POP.

Pessary fitting: ring, ring with support, Gellhorn, cube, and donut shapes; regular removal and cleaning reduces vaginal erosion and infection risk.

Risk factors for POP include vaginal parity, advancing age, obesity, chronic cough, connective tissue disorders, and prior pelvic surgery.

Obliterative procedures (colpocleisis) are appropriate for frail patients who do not desire future vaginal intercourse.

Symptomatic POP with coexisting occult stress incontinence may be unmasked after reduction; consider a staged or concurrent anti-incontinence procedure.

Stress incontinence = leakage with increased abdominal pressure; urge incontinence = leakage preceded by urgency; mixed = both.

Overactive bladder syndrome is defined as urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of infection or other pathology.

First-line management of urge incontinence includes bladder training, timed voiding, pelvic floor muscle training, and fluid/caffeine modification.

Antimuscarinics (oxybutynin, tolterodine, solifenacin) and beta-3 agonists (mirabegron) are second-line pharmacotherapy for OAB.

Midurethral sling (retropubic or transobturator) is a first-line surgical option for stress incontinence; Burch colposuspension is an alternative.

Urinary retention with overflow incontinence is suggested by elevated PVR; causes include detrusor underactivity and outlet obstruction.

Fistula (vesicovaginal) should be suspected with continuous leakage after pelvic surgery, especially following hysterectomy.

Fecal incontinence is classified as passive (internal sphincter dysfunction) or urge (external sphincter dysfunction).

Endoanal ultrasound grades sphincter defects; a defect of >30 degrees of the external anal sphincter is considered significant.

Anal manometry measures resting pressure (internal sphincter) and squeeze pressure (external sphincter).

Conservative management includes dietary fiber, antidiarrheals (loperamide), biofeedback, and pelvic floor muscle training.

Sacral neuromodulation is an option for refractory fecal incontinence with intact sphincter function.

Obstetric anal sphincter injury (OASIS) is a major risk factor for later fecal incontinence.

Rectal prolapse presents with a full-thickness protrusion; surgical repair (abdominal or perineal approach) is the definitive treatment.

Bacterial vaginosis: clue cells, pH >4.5, positive whiff test, thin gray discharge; treated with metronidazole or clindamycin.

Vulvovaginal candidiasis: thick white discharge, pH <4.5, pseudohyphae on KOH; treated with topical azoles or oral fluconazole.

Trichomoniasis: motile flagellates on wet mount, pH >4.5, yellow-green discharge; treated with oral metronidazole (partner treatment).

Uncomplicated cystitis in women: first-line agents include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin.

Recurrent UTI is defined as ≥2 infections in 6 months or ≥3 in 12 months.

Lichen sclerosus presents as white, thin, crinkled plaques, often on the vulva; biopsy is indicated for atypical lesions and treatment is potent topical corticosteroids.

Vulvar lichen planus may present with erosive lesions and vaginal involvement; biopsy helps distinguish it from lichen sclerosus.

Dyspareunia is classified as superficial (entry), deep (thrust), or both; each suggests different etiologies.

Vaginismus is involuntary pelvic floor muscle contraction preventing penetration; treated with pelvic floor physical therapy and graduated dilators.

Provoked vestibulodynia is vulvar pain localized to the vestibule, often with allodynia; first-line management includes topical lidocaine and pelvic floor therapy.

Endometriosis-associated pain may be cyclic; laparoscopy remains the diagnostic gold standard.

Interstitial cystitis/bladder pain syndrome is diagnosed clinically with pain and urinary urgency/frequency in the absence of infection.

Pudendal neuralgia presents with perineal pain, often worse with sitting; pudendal nerve block can be diagnostic and therapeutic.

Dysmenorrhea is managed with NSAIDs and hormonal contraceptives; secondary dysmenorrhea warrants evaluation for structural causes.

Preoperative antibiotic prophylaxis for pelvic surgery typically uses a first- or second-generation cephalosporin within 60 minutes of incision.

Venous thromboembolism prophylaxis is guided by Caprini risk score; mechanical and pharmacologic methods are combined for high-risk patients.

Postoperative urinary retention is common after pelvic surgery; PVR should be checked before discharge.

Enhanced recovery after surgery (ERAS) principles include carbohydrate loading, opioid-sparing analgesia, and early ambulation.

Mesh complications include erosion, extrusion, infection, and pain; management ranges from conservative to excision.

Postoperative fever workup includes atelectasis, UTI, wound infection, and, after hysterectomy, vaginal cuff cellulitis or abscess.

Perioperative glycemic control (target ~<180 mg/dL) reduces surgical site infection risk.

Oxybutynin is a non-selective antimuscarinic; its extended-release form reduces dry mouth compared with immediate release.

Mirabegron is a beta-3 adrenergic agonist that relaxes detrusor muscle and may raise blood pressure; monitor BP.

Topical vaginal estrogen improves urogenital atrophy and can reduce recurrent UTI in postmenopausal women.

Pessaries provide mechanical support for prolapse and are an alternative to surgery; regular follow-up prevents complications.

Pelvic floor muscle training is first-line for stress and mixed incontinence; supervised programs are more effective than unsupervised.

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, may improve stress incontinence symptoms but has adverse effects (nausea, fatigue).

Anticholinergic burden should be considered in older adults; cognitive impairment is a relative contraindication to antimuscarinics.

Informed consent requires disclosure of risks, benefits, alternatives, and the patient's right to refuse.

Shared decision-making integrates patient values with clinical evidence; it improves adherence and satisfaction.

Documentation should be contemporaneous, objective, and include the patient's questions and understanding.

Confidentiality is governed by HIPAA and institutional policy; disclosure requires patient authorization except as legally mandated.

Health literacy affects comprehension of pelvic floor instructions; teach-back technique verifies understanding.

Cultural and language barriers should be addressed with interpreter services; family members should not be used as interpreters for sensitive topics.

Professional boundaries include avoiding dual relationships and recognizing impairment or burnout in oneself or colleagues.