Clinical Curriculum: Urogynecology

Updated July 2014

GOAL: The primary goal of the Urogynecology rotation at the University of Alabama at Birmingham (UAB) is to train physicians to have a broad knowledge base and broad expertise in the evaluation and treatment of women with pelvic floor disorders. The combination of increased knowledge, hands-on evaluation, hands-on surgical experience and post-operative management will improve the healthcare of women in general.

Organization of inpatient and outpatient teaching: The majority of both inpatient and outpatient teaching is performed at the primary institution (UAB Medical Center, Women & Infants Center) and The Kirklin Clinic [TKC] which comprises the University of Alabama at Birmingham Hospitals and Clinics. Residents and fellows are involved in both inpatient and outpatient teaching during each of their clinic rotations.

In-patient teaching is organized within each clinical service (gynecology, urology, and colorectal surgery.)

Teaching includes:

(1) rounds attended by the fellows, faculty members, residents, and students (2) didactic presentations or interactive conferences held in addition to patient rounds • Monday Morning Pre-operative conferences 0630-0700 in the surgery lounge – led by Dr. Varner • Fellows Conference - 1st Wednesday of each month – 1700-1800 – led by UROGYN Division Faculty (3) didactic sessions prior to, during, and after surgical procedures • Tuesday Morning GYN and UROGYN didactic conferences 0700-0800 – led by UROGYN fellows and faculty

*These Teaching Conferences should be attended by all residents on the UROGYN Service

Each surgical procedure is attended by a faculty member and/or fellow and the resident progressively assumes more and more responsibility in the performance of surgical procedures.

Out-patient teaching is conducted at the Women & Infants Center and TKC. While rotating on the Urogynecology rotation, residents will attend clinic with FPM/RS faculty members in urogynecology approximately two to three half days weekly and become familiar with in-office UROGYN procedures/evaluations and proficient in evaluation, treatment choices, and patient consultation.

Supervision in operating room and clinic: Updated July 2014

Residents are directly supervised by faculty members at all times. Surgical faculty members are in attendance in the operating room during the critical portion of all procedures. The resident’s responsibilities increase based on individual assessments of expertise and with experience.

PGY Urogynecology Objectives PC MK PBL ICS P SBL Level Objectives Understand and describe the normal anatomic supports of the vagina, rectum, bladder, urethra, and uterus (or vaginal cuff in the setting of prior hysterectomy), including the 2,4 x x bony pelvis, pelvic floor nerves and musculature, and connective tissue. Describe the static and dynamic interrelationships and function of the pelvic organs 2,4 x x and support mechanisms Summarize the normal function of the lower urinary tract during the filling and voiding 4 x x phases, and the mechanisms responsible for urinary continence

Summarize the potential psychological, social, and sexual consequences of pelvic 2,4 x x floor disorders disorders Describe the principal etiologies of pelvic support defects, urinary incontinence, and 2,4 x x fecal incontinence, including effects of pregnancy and delivery Identify the anatomic defects associated with various aspects of pelvic support 2,4 x x disorders Characterize the major types of urinary incontinence 2,4 x x Describe abnormal urethral conditions, including urethral syndrome, urethritis, and 4 x x diverticuli Describe the possible etiologies, diagnostic strategies, and treatment approaches for 4 x x x interstitial cystitis Describe the various types of urinary voiding disorders and their possible etiologies, 4 x x including medical and surgical causes Describe the etiologies, prevention, diagnostic techniques, and approaches to repairing various ﬁstulae (rectovaginal and vesicovaginal) that may involve the pelvic 4 x x organs. Updated July 2014

Describe the symptoms that may be experienced by a patient with pelvic support defects, urinary incontinence, or fecal incontinence. Understand the importance of the 2,4 x x use of validated questionnaires to characterize these symptoms

Elicit a pertinent history in a patient with a suspected pelvic support defect, urinary 2,4 x x incontinence, or fecal incontinence

Perform a focused physical examination utilizing the Pelvic Organ Prolapse Quantification (POP-Q) system to identify and characterize specific pelvic support defects, including: Anterior compartment 2,4 x x Urethral hypermobility Posterior compartment Apical compartment (cervix/uterus or vaginal cuff)

Perform a focused physical exam in a patient with urinary and/or fecal incontinence, including assessment of: Bladder and urethral support 2,4 x x Perineal, levator, and anal sphincter strength Neurologic status Perform and interpret the results of selected tests to characterize urinary incontinence disorders, including: Assessment of residual urine volume 2,4 x x Simple cystometry Q-tip test

Describe the indication for, and interpret the results of other diagnostic tests, such as: Urinalysis Urine culture Cystourethroscopy Multichannel cystometry Urethral proﬁlometry 4 x x Uroﬂowmetry Radiologic tests Electromyography Assessment of anal sphincter integrity (e.g., endoanal ultrasound, manometry, radiologic imaging studies, neurologic testing) Updated July 2014

To provide experience in the treatment of urogynecologic disorders by both nonsurgical (e.g., pelvic floor exercise regimens, physical therapy, pessary) and 4 x surgical methods Describe the types of injuries or complications that may occur related to medical and surgical treatments of urogynecologic disorders, and the approaches to managing 4 x them Describe appropriate follow-up for a patient who has been treated for a urogynecologic 4 x x x disorder To provide residents the ability to perform research studies including mentoring them 2,4 x x x x x in the planning and performing of meaningful research in this field, if interested

UroGyn Procedures

The following Table lists the additional procedures that are specific to Urogynecology and female pelvic reconstructive surgery and summarizes the level of technical proficiency that should be achieved by each year level resident.

*Depending on the skill of the individual resident, PGY4s may be able to assist and/or perform the more complicated procedures (listed as ‘understand’) during the rotation but may not be expected to independently perform after graduation.

Understand Procedure Understand and Perform

Colporrhaphy (uncomplicated or primary)

• anterior 2, 4 2, 4

• posterior 2, 4 2, 4 Colporrhaphy (complicated or repeat)

4 • anterior 4 • posterior Updated July 2014

Total vaginal hysterectomy 2,4 2, 4

Cystoscopy 2,4

Midurethral sling 2,4 4

Perineorrhaphy 2,4

Uterosacral vault suspension (associated with the performance of a TVH in women with Stage 2 prolapse or 4 less)

Colpocleisis procedure 4

Open, laparoscopic or robotic sacrocolpopexy 4

Fistula repair

4 • Rectovaginal

• Vesicovaginal 4 4 • Uretero/urethrovaginal Apical/Enterocele repair 4

Anal manometry 4

Endoanal ultrasound 4