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Electives - Obstetrics and Gynecology

ACE - AI Female Pelvic Medicine/Urogynecology

Elective Number: 1919

Rotation Supervisor: Dr. Elisa Trowbridge

Coordinator: Tammy Lull, tl5s@virginia.edu

Available: 2, 3, 4, 5, 7, 9, 12, 13

Duration: 4 weeks

Report to: Dr. Elisa Trowbridge

Time to Report: 8:00 am

Place to Report: Northridge Suite 305

Typical Day: 7:30 am - 5:00 or 6:00 pm

Attendance: A student may not take time off during an ACE.

Suggested preparatory reading: Ostegards Urogynecology, and other selected articles to be given out by the attending

Number of students per rotation: 1

Course Description: Students will have the opportunity to evaluate ambulatory patients several days a week with attending physicians (Dr. Kathie Hullfish and Dr. Elisa Trowbridge) and the residents on service. Students will be responsible for taking a targeted history, with the ultimate goal of being able to demonstrate proficiency and independence in the performance and evaluation of a gynecologic examination, with particular emphasis on pelvic floor dysfunction. Written clinic notes will be completed by the student and co-signed by either the attending physician or the resident. Outpatient activities will alternate with the opportunity to assist and/or observe surgical procedures throughout the week. In the operating room, the student will scrub or observe on cases and assist the resident with all aspects of post-operative care, including orders, post-op notes and daily rounds. The student will be responsible for seeing all inpatients twice a day with two progress (SOAP) notes in the chart, co-signed by the resident and/or attending.

The student will be responsible for providing one 15 minute presentation on a gynecologic topic of their choice, agreed to by either Dr. Hullfish or Dr. Trowbridge. This will be presented to the team, using evidence-based research skills and PowerPoint, during one of the didactic sessions at the end of the rotation.?Primary literature and resources will be made available to the student on our Division's computerized "O" drive. (O drive/OBGY/FPM resources). Permission is granted on the student's first day on service. Other reading materials will be provided by Dr. Trowbridge and/or Hullfish.

The student may be able to observe multi-channel urodynamics in our outpatient clinic. They may also be able to observe other Urologic or Colorectal Surgeries, and sessions of pelvic floor physical therapy as time and/or interest permits.

Feedback about this rotation from the student will be encouraged. The student will meet with one of the supervising attendings at the end of the rotation for a feedback session.

UROGYNECOLOGY ACE LEARNING OBJECTIVES

BASIC SCIENCES

ANATOMY
Objective: The Medical Student should demonstrate an understanding of the normal anatomy and anatomic interrelationship variations of the bony pelvis, and pelvic floor musculature, nerve supply, vasculature, connective tissue supports, and the pelvic viscera including the bladder, ureters, urethra, vagina, uterus, rectum, sigmoid colon, small bowel and surrounding structures.
1. Be familiar with the alterations in normal anatomic relationships associated with pelvic organ prolapse and urinary and anal incontinence

PHYSIOLOGY
Objective: The medical students should demonstrate a working understanding of the normal function of the lower urinary tract during the filling and voiding phases, the factors responsible for anal continence, and the key elements involved in normal pelvic floor support.
1. Understand the autonomic and somatic neurologic control of lower urinary tract function.
2. Understand the normal bladder capacity and voiding frequency.
3. Be familiar with the role of neurotransmitters and receptors in coordinated bladder and urethral function.
4. Be familiar with the functional sphincteric mechanisms of the urethra.
5. Recognize how vaginal delivery, estrogen, aging, obesity, health habits (like smoking, chronically straining at bowel movements, and chronic cough), and pelvic surgery may impact lower urinary tract function; muscles, and lower intestinal function.

HISTORY AND PHYSICAL EXAMINATION

THE PELVIC FLOOR
Objective: The medical student should be able to perform a complete history and physical examination to evaluate lower urinary tract symptoms and signs.

Objectives (History)
1. Apply standard terminology as related to signs and symptoms of lower urinary tract disorders (e.g.urgency, urge incontinence, stress incontinence as a symptom, a sign, and a syndrome.)
2. Evaluate the severity and impact on the quality of life including its impact on social and sexual function.
3. Evaluate past medical and surgical histories as they might relate to urinary tract symptoms.
4. Be familiar with the possible relationship of current medications to lower urinary tract symptoms.
5. Apply standard terminology as related to signs and symptoms of lower urinary tract disorders (e.g., urgency, urge incontinence, stress incontinence, nocturia).
6. Evaluate past medical and surgical histories as they might relate to urinary tract symptoms.
7. Evaluate the possible relationship of current medications to lower urinary tract symptoms.

Objectives (Physical Examination)
1. Be familiar with how to perform a thorough pelvic physical examination including neurologic examination.
2. Be aware of the quantitative staging systems for pelvic organ prolapse (e.g. POPQ).
3. Be familiar with the three compartments of prolapse (anterior, apical, posterior).
4. Recognize stress urinary incontinence on physical examination.

GENERAL CONSIDERATIONS
Objectives:
1. Incorporate screening questions regarding urinary incontinence in appropriate patients.
2. Understand the differences between stress urinary incontinence, urge urinary incontinence and overflow urinary incontinence.
3. Obtain an appropriate history to differentiate these types of urinary incontinence.
4. Identify behavioral, medical and surgical treatments for urinary incontinence and pelvic organ prolapse.


SPECIFIC DISORDERS:

STRESS INCONTINENCE
Objectives:
1. The medical student should understand the principles involved in the diagnosis of stress incontinence.
2. Be familiar with the various approaches, both nonsurgical and surgical, for the treatment of genuine stress incontinence.
3. He/she should know when referral for further evaluation and treatment is appropriate.

URGE INCONTINENCE
Objectives:
1. The medical student should understand the principles involved in the diagnosis of urge incontinence.
2. Understand the clinical presentation of the condition and other conditions from which it must be distinguished such as infection or neurologic etiologies.
3. Be familiar with the various approaches, both nonsurgical and surgical, for the treatment of urge incontinence.
4. He/she should know when referral for further evaluation and treatment is appropriate.

URINARY RETENTION / OVERFLOW INCONTINENCE
Objectives:
1. The medical student should understand the clinical presentation of the condition and other conditions which are similar in presentation.
2. Be familiar with the diagnostic measures ( e.g. Post void residual) and the need for referral for this condition.

URODYNAMIC EVALUATION
Objective:
1. The medical student should be familiar with the terminology, basic testing methods and information that may be obtained from the tests.

URINARY TRACT INFECTION
Objective: The medical student should be able to diagnose acute, chronic, and recurrent infection of the urinary tract in both pregnant and nonpregnant women.
1. Understand terminology (e.g. bacturia, pyuria, chronic infection, reinfection, relapse, asymptomatic bacturia).
2. Understand pathophysiology (e.g. Host responses, age relationship, influence of pregnancy, etc.).
3. Identify the difference between complicated and uncomplicated infections.
4. Be familiar with methods and significance of diagnostic techniques.
5. Understand modes of therapy for acute infection.
6. He/she should be able to treat acute infection of the urinary tract in women.
7. Understand predisposing factors, including anatomic, and the indications for referral for further evaluation.

PAIN DISORDERS
Objective:
1. The medical student should demonstrate an understanding of the different pain disorders referable to the urethra and bladder.

PELVIC ORGAN PROLAPSE
Objectives:
1. Recognize that childbearing, age, obesity, and genetic factors are associated with pelvic organ prolapse.
2. Describe the anatomic and symptomatic consequences of abnormal pelvic floor support.
3. Be familiar with the indications for treatment.
4. Identify the role of nonsurgical (including care and use of pessaries) and surgical treatment options.
5. Understand the indication for referral (i.e. symptomatic prolapse and especially any prolapse past the introitus).

ANAL INCONTINENCE
Objectives: The medical student should:
1. Recognize the multiple etiologies of anal incontinence (e.g. stool transit, colonic capacitance, anal sensation and sphincter function).
2. Understand the psychological, social, and sexual impact of fecal incontinence.
3. Describe the role of nonsurgical and surgical therapy in the treatment of anal incontinence.

PROCEDURES
Potential procedures that medical students should be able to demonstrate:
1. Pelvic examination skills such that a medical student could identify prolapse if presented with an image or patient with the condition.
2. Female urethral catheterization.

VISITING MEDICAL STUDENTS: Completing a visiting student rotation does not guarantee an interview for residency.