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MRCOG & DRCOG, MRCOG II SGA notes updated - fetal Med module New Essays: New essay questions will be posted in the discussion forum from Mon 17/06/13 (2 weeks earlier than normal). There will be no essays in the 2 weeks from 22/07. Answers will be marked on a first-come-first-served basis with a marking scheme posted after 7 days. Answers posted after the marking scheme will not be marked and will be deleted. Using this Course: (1) Register. (2) Log-in (3) Click 'Join this Course' to get 2 days FREE TRIAL. (4) After 2 days, you will automatically be taken to subscription page when you access the material. Fees for MRCOG II course are: £285 for 12 months, £195 for 6 months, £180 for 5 months, £150 for 4 months, £115 for 3 months, £100 for 2 months and £85 for 1 month. |
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 SGA notes updated - fetal Med module New Essays: New essay questions will be posted in the discussion forum from Mon 17/06/13 (2 weeks earlier than normal). There will be no essays in the 2 weeks from 22/07. Answers will be marked on a first-come-first-served basis with a marking scheme posted after 7 days. Answers posted after the marking scheme will not be marked and will be deleted. Using this Course: (1) Register. (2) Log-in (3) Click 'Join this Course' to get 2 days FREE TRIAL. (4) After 2 days, you will automatically be taken to subscription page when you access the material. Fees for MRCOG II course are: £285 for 12 months, £195 for 6 months, £180 for 5 months, £150 for 4 months, £115 for 3 months, £100 for 2 months and £85 for 1 month. |
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Do you realy want to delete this discussion?
Forum >> Essay 280 - urinary incontinence
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Posted by PAUL A. Sat Jan 10, 2009 02:10 pm |
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| a.I will take a detailed history regarding duration ,severity of symptoms and the quality of life (1) affected due to these symptoms.Other symptoms like frequency,urgency and urge incontinence suggestive of over active bladder syndrome (1) will also be enquired. Pain on voiding suggestive of UTI and hesistancy,poor stream suggestive of outflow obstruction (1) will also be enquired.Nocturia,bed wetting,use of incontinence pads and toilet mapping will be asked.Any mass in abdomen suggestive of fibroid and history suggestive of prolapsed (1) prolapse symptoms will be enquired.Her fluid intake,caffeine and alcohol intake (1) which may predispose to urgency ,if present,will be enquired.Previous incontinence surgeries (1) ? obs Hx and fertility wishes if done any and her wishes for treatment will be enquired. b.This will include general examination for BMI and blood pressure for planning the management.Speculum examination will be done to rule out the presence of any prolapse (1) d.Bimanual pelvic examination to be done for the presence of any abdominal pelvic mass ? will you examine her abdomen? . c. Initial investigation include MSU,dipstixfor protein,blood[UTI],nitrites and glucose (1) .Frequency volume chart to be maintained to assess the severity of the condition.USS pelvis will be done to detect urinary residual volume (1) . Urodynamic study will be done if there are mixed symptoms no – treat most significant symptom first or symptoms not responding to conservstive management.Cystoscopy is indicated if there is persistent hematuria. d.Further treatment options may be surgical or medical.Open Burch colposuspension (1) it is the gold standard but not the first line. Less invasive procedures like TVT are now offered first remains the first line surgical management.This elevates the paravaginal tissue to the ipsilateral illiopectineal ligament and has a continence rate of 80-90%in 1 year and 70% in 5 years (1) . Complications include voiding dysfunction,denovo detrusor instability[10%],long term self catheterization,development of enterocele[10%],operative morbidity not necessary – not asked to critically evaluate . Laproscopic colposuspension do not have similar success rates is it higher or lower?? due to less number of sutures used and depends on surgeon skill.This is costly but has the advantage of less post operative morbidity and hospital stay. Sling procedures like TVT which support the mid urehtra can be done under local anaesthesia (1) .Success rate is 70-80% in 1 year but long term trials are awaited. Complications include bladder injury,detrusor instability,voiding dysfunction,tape erosion not needed .Long term success rates for TOT procedure are awaited what are the short-term rates?? .Marchelli-Marchetti-Krantz procedure not widely used due to risk of osteitis pubis.Needle suspension procedures not done as first line surgical treatment due to morbidity. Anterior colporraphy ? value in a woman with normal clinical examination with bladder neck buttressing has a low success rate.Intramural bulking agents like collagen,glutaraldehyde have lower success rates (1) ,higher morbidity and can be used in failed cases. Medical management with duloxetine [SSNRI] at a dose of 40 mg/day can be given if unfit or surgey is declined.Side effects include gastro intestinal disturbance,headache,nausea and anorgasmia. |
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Posted by PAUL A. Sat Jan 10, 2009 02:19 pm |
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| Am a- Taking history is very important because it will categorize patients regarding types of urinary incontinence . This is best established by giving the patient a 3 days bladder diary this is an investigation to be completed before her clinic appointment .This will include data about fluid intake ,frequency of going to the toilet, amount voided ,associated symptoms like pain and urgency . It will also reflect the impact of her complaint on quality of life (1) , her daily activities and personal relations . We will then discuss her complaint details and ask about timing and details of her deliveries (1) if normal or operative vaginal or by cs and whether associated with complications or no. History of previous treatment for incontinence (1) medical or surgical ,previous pelvic surgery, , pelvic irradiation ,, flatus and fecal continence (1) will influence therapy. Personal history of diabetis m or multiple sclerosis read the question - HEALTHY should be excluded .Constipation and chronic cough are relevant complaints. b- General examination must include body weight and BMI. Abdominal examination for masses (1) and inguinal lymph nodes . Pelvic examination for prolapse (1) , vaginal hygiene and infections ,pelvic masses and integrity of pelvic floor muscles should be done . c- Mid stream urine sample will be tested for glucose ,nitrite , RBCs and leucocytes . If nitrite is positive then culture and sensitivity (1) will be ordered. I f heamaturia is present referral will be adviced . d- Treatment for urodynamic stress incontinence is initially conservative in the form of pelvic floor muscle training lasting three months . 8 to 12 contractions are repeated 3 times daily . Success rates are good but relapse is common if exercises are stopped . If PFMT didn t improve her symptoms waste of time / space – YOU ARE CLEARLY TOLD THAT THIS HAS FAILED the second line will be surgical after exclusion of urge or mixed incontinence you are telling the examiner that you have not read the question or do not know what URODYNAMIC stress incontinence means . Retropupic mid urethral tape procedures using macroporous proline mesh has similar success rates to open colposuspension 80 % to 90 % after 1 year and 75 % after 5 years (1) you were asked to evaluate the options – to gain full marks, every option should be evaluated separately . Rates of complication depends on the experience of the operator . Bladder perforation in tape procedures occurs in 9% compared to 2% in open colposuspension not necessary – not asked to critically evaluate but with less bleeding and shorter hospital stay . Mid urethral tape procedures can be done transobturator but long term results are unclear what are the short-term results? . Needle suspension is not recommended because of high failure rate 85% after 1 year . Anterior colpoperineoraphy ? value when clinical examination is normal and Marshal Marchetie operations are not recommended because the newer procedures give better results and ostitis pubis occurs in the later . Doluxitine is not given except in women declining or unfit for surgery. It is a serotonine noradrenaline reuptake inhibitor . Its main side effect is nausea . Intra mural urethral bulking agents as macroplastique , collagen and silicone are used in cases of intrinsic sphincter deficiency. They give only short tem good results but may migrate , need repeated injections and need long follow up. Artificial sphincters are only used if other procedures failed. |
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Posted by Ashwinibilagi25 B. Sat Jan 10, 2009 07:12 pm |
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| A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks] parity and mode of del time duration after last delivery/is she pregnant now? duration of problem/fluid intake/caffiene intake frequency nocturia incomplete emptying, urgency frequency of incontinace and efect on quality of life mass per vagina/dragging sensation sexually active? other medical problems especially connective tissue disorders (b) What information would you obtain from the clinical examination [2 marks] P/A to r/0 mass per abdo P/s in left lateral position to perform POP Q score to r/o prolapse, bladder neck mobility on straining to assess the strength of pelvic floor (c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks] MSU dailty fuid intake diary bladder diary Urodynamics (d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence. Evaluate the subsequent treatment options [6 marks]. taking her age in to consideration, options would be supportive management can wait and watch for some more time if it is not affecting the quality of life which is rare in a 40 year old with future clinic apt to kno the progress surgical methods Burch colpo suspension pros 80 -90 % success in first year 70 % patient satisfaction rate permanent solution no dysparaunia cons needs laparotomy about 10.3 voiding problems post surgery prolonged poeration time tot/tvt pros no laparotomy can be performed as a day case 1 st year success rate comparable to colposuspension sooner recovery con dysparaunia tape erosion /infection injury to bladder & ureters vioding difficulties comparable to colposuspension laparoscopic colposuspension prso aviods laparotomy cons longers operating time needs expertise ileo sacral suspension(laparoscopic) long op tme no long time studies available |
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Posted by PAUL A. Sat Jan 10, 2009 08:03 pm |
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| A. A detailed history should be obtained regarding duration, severity, frequency, regular use of sanitary towels and the impact of this problem on her quality of life (1) . Other urinary symptoms such as urgency, urge incontinence, haematuria, voiding problems, urinary infection and overactive bladder symptoms this suggests that you do not know that urgency and urge incontinence mentioned earlier are symptoms of overactive bladder in form of frequency nocturia etc how does the examiner know that you know what is included in etc? should also be asked to classify type of incontinence. Symptoms of faecal incontinence (1) should also be reported. Precipitating factors which predispose to increased intra-abdominal pressure such as chronic cough including history of smoking, constipation and obesity should also be inquired. It is a good idea to know drinking habits- use of caeffine, alcohol (1) and diuretics. Obstetric history is also important to know – number of previous pregnancies, duration of labour, instrumental delivery and big sized babies as all these predispose to damage to urogenital system. An enquiry should also be made regarding future fertility plans (1) . A history of abdomino-pelvic masses such as big fibroids, ovarian lumps which may cause leakage because of the pressure effect in addition to prolapse symptoms (1) should also be obtained. In surgical history it is important to know any past history of any abdominal or pelvic surgery resulting ureter or bladder damage including use of radiotherapy which would influence future surgery. Any past history of any surgery for incontinence or conservative measures taken (1) should also be documented. B. General examination should include height and weight to calculate the body mass index (BMI). Lungs should be auscultated to rule out chronic chest problem. Abdominal examination should be done to palpate abdominal or pelvis masses or bladder (1) . Local examination should be done to assess leakage on coughing in case of stress incontinence or triple swabs test to know site of fistula. Speculum examination should be done to see degree of prolapse in cases of prolapse symptoms (1) . Bimanual examination should also be done to palpate pelvic masses. An Oxford scoring assessment should also be done to know the tone of pelvic floor. C. I would test urine dipstix and urine culture sensitivity if she is symptomatic or positive nitrate or leucocytes on dipstix (1) . A bladder scan should be organized if palpable bladder or positive history of voiding problems or chronic repeated urinary infections. She should also be asked to keep volume frequency diary (1) to assess degree and type of incontinence. Abdominal or pelvic scans should be organized if there is any doubt about them. D. Before attempting any surgery, she should be asked about her desire of fertility. Surgery should be delayed until she has completed her family why should a young woman put up with incontinence for several years until her family is complete? Would you accept this if you were wetting yourself every time you coughed or laughed while relatively simple day-case operations were available? . Retropubic mid-urethral polypropylene tape is the surgery of choice. Success rate is operator dependant approximately 95% (1) . Long term data is not available. She should be warned you are not answering the question. You were not asked about what should be done of the complications in form of voiding difficulty (6%), damage to bladder, reactions to tape and detrussor overactivity not necessary . Advantages are short operating time, quick recovery, short hospital stay, can be done under local anaesthesia (1) . Transobturator tape is the other preferred surgical procedure for stress incontinence. Bladder injuries are less likely with this procedure compared to mid-urethral tape. Long term data are not available what are the short-term data? . Burch open colposuspension has been practiced since long time. Long term data are available. Success rates are 95% (1) at 10 years???? . Complications are bone necrosis, voiding difficulty and detrussor overactivity not needed – not asked to critically evaluate. Bone necrosis of which bone?? . It can be done laparoscopically but success rates are poorer than open surgery (1) . Therefore it is not recommended routinely by NICE guideline. Autologous rectus fascial sling is other available option. Intramural injections of bulking material such as glutaraldehyde, silicon and collagen can be given in women who are at high risk for anaesthesia answer the question – is this woman high risk? or surgery. However they should be aware of need of repeated injections, reduced efficacy with time and poor outcome compare to retropubic sling or suspension. Artificial sphinctors are last but not the least available surgical procedure for this condition. These women need regular long term follow up after this surgery. Other surgical options are Marshall Marchetti Kranz procedure, needle suspension, anterior repair are not recommended by NICE either. |
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Posted by PAUL A. Sat Jan 10, 2009 08:19 pm |
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| A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks] I would ask the patient if she has other urinary symptoms ,urgency,urgency incontinence or nocturnal enuresis which may point to associated detrusor overactivity (1) , dysuria or hematuria which may be due to associated urinary infection (1) .I will ask of associated incontinence to faeces or gas (1) . I would go through her obstetric history and difficulties encountered need to be more specific , past gynecological history including presence of vaginal wall prolapse prolapse symptoms – the woman will not be expected to know if she has a prolapse , fibroids and wether vaginal operations were done to her, past medical history including chest problems, constipation, and any previous medical treatments given for her condition. I would ask her of the effect of her symptom on her quality of life (1) , her fluid intake including coffee (1) and alcohol . I would ask her of her smoking habits and her life style wether it includes excercises like squash where her symptom might be distressing. (b) What information would you obtain from the clinical examination [2 marks] Iwould measure BP , her BMI ,do chest examination for chest problems,and abdominal examination for abdominal masses (1) .I would look for ammonical dermatitis in vulval region and perinea area. I would ask her to strain and see if associated cytokine ??? ,and ask her to cough to demonstrate her symptom but this is not always demonstrable . I will do local exam to feel mobility , position and size of uterus.I would feel mobility of urethera and do Bonney test ? presence of prolapse c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks] I would do MSU to exclude infection (1) , do urine dipstiks exam for proteins, nitrates which denote infection, glucose which may denote diabetes mellitus, and blood which denote hematuria needing further investigations like cystoscopy. I would do urinary diary (1) to measure aount and frequency of voided urine to tell me an idea about urinary capacity.Urodynamic studies are not done at this stage. d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence. Evaluate the subsequent treatment options [6 marks]. Medical treatment with Dolexetine should not be first choice so why are you writing this first? after failed conservative treatment due to frequent side effects(nausea and vomiting) ,but could be used if patient does not want to have surgery.It is an effective treatment as it act on uretheral sphincter making it more continent( An SSNRI inhibiting the reuptake of serotonin and nor epinephrine) Tension free vaginal tape TVT is taking over Burch colposuspension as a surgical procedure for treatment of GSI USI as stated in the question , being simpler, can be done under local anaesthesia in a day case surgery, less operative and postoperative complications , cost effective (1) and at same time gives same results with continence rate in 80% of patients over 5 years (1) does this mean 80% are dry??.TVT secure can be used and is less invasive than TVT. Transobturator tape is being used and results are awaited. It has the advantage over TVT in that there would be no injury to the urinary bladder and so cystoscopy is not needed to check while being applied.Burch colposuspension can be done laparoscopic ally but resuts are less what about open colposuspension? . In patients who are surgical risk answer the question asked. Does this apply to this woman? parauretheral injection of synthetic material can be effective but long term results are low and need further injection (1) . Older procedures ,like Kelleys suture or Stamey needle procedures have low cure rate and fell out of use. The use of mechanical methods to close the urethera might be a temporary method in situations like playing squash in patients who decline surgery |
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Posted by PAUL A. Sat Jan 10, 2009 09:25 pm |
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| A) The duration and severity of her symptoms and the impact on her daily life (1) quality of life should be enquired. Other urinary symptoms such as urgency, frequency and urge incontinence (1) should be asked as many women may have mixed incontinence. Symptoms of dysuria or haematuria may suggest urinary tract infection (1) or other more sinister causes. Obstetric history should be explored and any previous difficult vaginal deliveries especially with macrosomic babies noted . History of chronic cough or constipation should also be identifiend. Other co-morbidities should be enquired to assess patient\'s fitness for surgery HEALTHY . Past surgical history should be enquired especially any previous continence surgery done (1) . Finally the woman\'s desire for treatment and whether she has completed her family should be enquired (1) ? prolapse symptoms. B) The weight and height should be noted to assess her BMI. Presence of any abdominal or pelvic mass should be noted (1) perform abdominal examination . Pelvic examination should be carried out to assess for uterovaginal prolapse (1) if present. Stress incontinence may be demonstrable with cough test. C) Initial investigations include urine analysis and culture to exclude urinary tract infection. The woman should be asked to use frequency-volume chart and urinary diary. D) Duloxetine which is a serotonin and noradrenaline reuptake inhibitor may be offered when conservative treatment fails and the woman prefers pharmacological to surgical treatment or not suitable for surgical treatment is this 40 year old healthy woman unfit for surgery? . It has been shown to be effective to reduce incontinence episodes and improve quality of life. However long term data is unavailable. Use of duloxetine are associated with side effects such as headaches, nausea, GI disturbance, reduced libido and also withdrawal reaction. Burch colposuspension is the most effective surgical treatment for stress incontinence. It has high continence rate at 1 and 5 years (1) what is high? 99%???. It may be done laparoscopically or open. Open colposuspension may be more successful compared to laparoscopic approach. Complications include de novo detrusor overactivity, voiding disfunction and posterior vaginal wall prolapse not necessary – not asked to critically evaluate . Sling procedures using autologous or synthetic materials produce success rates of simmilar to colposuspension at 5 years. TVT may be performed under local anaesthesia or as day case (1) . It is suitable for woman who has had previous colposuspension or in cases with low urethral pressure. It is associated with de novo detrusor overactivity, voiding dysfunction, bladder perforation, intra-operative bleeding and erosion of sling long term not necessary . Trans obturator foramen approach may be used to avoid risk of bladder injury. However long term data is not available are there short term data? . Other options include injectable agents administered at periurethral tissue or bladder neck. It is associated with low morbidity but the success rate is low and the effect declines with time (1) . Artificial sphincter may be used in failed surgery but it is associated with high morbidity and re-operation rates. |
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Posted by PAUL A. Sat Jan 10, 2009 09:41 pm |
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| ( a ) History There are 10 marks for (a) and 6 for (d) yet you dedicated more time and space to (d) should be taken regarding the severity of symptoms and its effect on quality of life (1) . Her mode of delivery should be asked for including history of difficult vaginal delivery or instrumental vaginal delivery (1) . Any history of perineal injury should be looked for. Whether the symptom follows from child birth or developed thereafter. History of excessive fluid and caffeine intake (1) should be taken. H/O recurrent UTI, presence of haematuria or continuous leakage of urine should be taken (1) . Presence of urge symptom should be asked for. Presence of chronic constipation should be looked for. ( b ) Abdomino pelvic examination is to be done to exclude any abdomino pelvic mass (1) . Vaginal examination is to be done to detect presence of any degree of urogenital prolapse (1) .Voluntary pelvic floor muscle contraction and perineal sensation should be assessed. ( c ) Mid stream specimen of urine (1) should be tested for presence of leukocyte ,blood, sugar or nitrate and culture & sensitivity if indicated. Frequency and volume chart and urinary diary (1) should be maintained. Pelvic ultrasonography is to be done to detect any lower abdominal mass. (d ) After failed conservative treatment she should be counselled you were not asked to counsel or treat her. You were asked to evaluate the options for surgical treatment regarding effectiveness and complication of various procedure. Choice of operation is dependent on presence of other pathology such as prolapse read the question – CLINICAL EXAMINATION NORMAL , fitness for surgery read the question – HEALTHY 40 YEAR OLD WOMAN , mobility of bladder neck, maximum urethral closure pressure, likelihood post operative voiding difficulty or detrusor overactivity, surgical expertise and objective success rate. Retro pubic procedure-Burch colposuspention associated with continent rates of 85% to 90% at 1 year And 70% at 5 years (1) . Operation shows better longevity than other procedure better than TVT?? and has similar short term continence rates to suburethral sling procedure .Increase risk of failure in patient with low urethral resistance. Risk of denovo detrosor over activity 17%(8-27%), voiding dysfunction 10%(2-27%), enterocole or rectocole formation 14%(3-27%) after 5 years not necessary – not asked to critically evaluate . Retropubic procedure have better outcome compare to anterior repair colposuspension is the gold standard to which all other procedures are compared 11% and 24% failure rates why are you quoting success rates for colposuspension and failure rates for retropubic procedures? respectively at one year. Benefit of colposuspansion is maintain for 5 years while that of anterior repair diminishes rapidly 25% and 69% failure rates respectively at 5 years. Sling procedure : Pubo urethral sling, tension free vaginal tape. Suitable in case of low urethral pressure . Success rates of 85-90% at 5 years(No long term data is available for TVT) (1) . 86% of objective cure rates at 3 years, 8% risk of bladder injury. Risk of denovo detrosar over activity 3-15%, risk of voiding dysfunction 4.3%. Errosion of sling may occur several years after surgery not necessary . Anterior colporrhaphy you mentioned anterior repair earlier or is anterior colporrhaphy a different operation??? -poor success rates, continent rates of 66% at one year, 37% at 5 years. Needle suspension associated with low perioperative complication but poor long term outcome only18% at 5years. Other surgical procedure-collagen or micro plastic injection low success rate 48% continence with 76% improvement in short term which decline with time (1) . Selected in woman with intrinsic sphincter deficiency. you need to be consistent – you either quote success rates or failure rates, not a mixture otherwise patients (and the examiner) get confused |
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Posted by PAUL A. Sat Jan 10, 2009 09:50 pm |
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| A. Her symptoms of urinary leakage on coughing and straining are suggestive of urinary stress incontinence. The severity and duration of symptoms should be enquired. The impact of symptoms on quality of life (1) should also be asked. Her fertility wish and desire for treatment should also be asked. Her sexual function and her expectation should also be considered. Other symptoms such as urgency, frequency (1) suggestive of urge incontinence should also be noted. Symptoms of urinary tract infection (1) such as burning sensation, dysuria, frequency should also be asked. History of delivering large babies followed by instrumental vaginal delivery (1) may have an impact to her symptoms. History of constipation, chronic obstructive lung disease may aggravate her symptoms. Other medical problems such as diabetes should also need to be explored HEALTHY woman . Her medication also need to be reviewed and may be associated with urinary incontinence including sedatives, diuretics. Previous continence surgery (1) may influence her management. Social circumstances need to be consider including home environment, personal relationship, occupational history and life style factors such as smoking need to be enquired. B. Abdominal examination should be performed to rule out any pelvic mass or palpable bladder (1) . Pelvic examination need to be done to assess uterovaginal prolapse (1) . C. She should complete voiding diary at least 3 days (1) covering variation in usual activities. Urine dipstick test need to be done to detect presence of blood, glucose, protein, leucocytes, nitrates. If leucocytes and nitrates detected, mid stream urine should be send for culture and sensitivity (1) . D. Surgical management is another option if conservative management failed to improve her symptoms. Choice of operation dependent on the presence of prolapse read the question – clinical examination NORMAL , surgical expertise and her wishes particularly with respect to the risk of long term voiding dysfunction. Retropubic mid urethral tape procedures such as tension free vaginal tape is recommended for her. Tension free vaginal tape has 80-90% (1) ? at 10 years?? efficacy, and can be performed as day care procedure with faster recovery local anaesthesia, more cost-effective . However, tension free vaginal tape has risk of bladder perforation, mesh erotion, infection, denovo detrusor instability, and voiding difficulty not necessary – not asked to critically evaluate . Burch colposuspension is another alternative and has 80-90 % success rate at 1 year (1) what about 5 years? but it has complication of urinary tract injury, wound haematoma, denovo detrusor instability, enterocele formation and voiding dysfunction not necessary . Synthetic slings using transobturator foramen approach is recommended as alternative options however she should be made aware of the lack of long term outcome data what do short-term data show? . Intramural bulking agent using silicone, collagen has lower efficacy compare to that of retropubic suspension or sling. She should be explained that repeated injection may be required to achieve efficacy and efficacy diminishes with time (1) . She should be given information leaflet regarding her treatment option to allow her to make informed consent. not answering the question – you were asked about the value of the options not what should be done to the patient |
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Posted by Seema B. Sun Jan 11, 2009 12:33 am |
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| Dear Dr Paul You have skipped correcting my answer.Can you please correct it.Awaiting to see the correction thanks seema |
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Posted by PAUL A. Sun Jan 11, 2009 03:15 am |
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| (a): Further informations in this case will be asking about daily intake of fluids, amount of tea & cofee (1) and number of times emptying bladder in the mor ning or at night. Type of incontinence will be inquired, whether urge or stress or mixed incontinence will the woman know what mixed incontinence is? . History of medical codition which result in increase in abdominal pressure such as constipation or chronic cough. Any probelm with nervous systems affecting nerve supply such as Multiple sclerois. Details of medication such as diuretics read the question - HEALTHY . Severity of symptoms asked which affect the quality of life (1) & need for use of incontinence pads. Other symptoms of dysuria, interrupted stream, and incomplete emptying (1) . Obstetrical history is obtained , number of children & mode & complexity of deliveries ? family complete . Any previous pelvic surgery,pelvic irradiation or surgery for incontinence. Family history of diabetes will be asked. prolapse symptoms (b) Abdominal examination may demonstrate a fibroid which may be cause of leaking due to pressure ? other abdominal mass . Vaginal examination show the presence of ant wall prolapse if any or uterovaginal prolapse (1) . Stress incontinence may be demonstrated while asking the patient to cough. Laxity of vaginal wall and power of contraction for vaginal wall is checked. (c) Mid stream urine is sent for Culture & sensitivity to rule out infection (1) . Patient is refered for urodynamics.for confirmation of diagnosis of GSI not necessary – GSI is old terminology .Blood glucose levels are checked to rule out diabettes (d) Further options are commencing her on SNRI sush as Duloxetine if there is no contraindication such as pregnancy or epilepsy read the question - healthy ,Side effects such as GI upset and headache. Medical treatment is not first line so why are you writing it first? , it may be considered if patient is not fit for surgery or prefer pharmacological treatment.,Mechinical devices may be cosdered. In surgical Colposuspension ,TVT and TVT-O are discussed not answering the question. You were not asked to discuss treatment options. You were asked to EVALUATE the options . There long term results and complication are explained do you know what the long-term results are? . Burch Colposuspension has complications of de novo detruser instability, voiding disorders & rectocoele & enterocoele. TVT has potential complication of mesh erosion, infection and de novo detrusor instability EVALUATE = attach value to. So what is the value of these operations??? . |
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Posted by PAUL A. Sun Jan 11, 2009 03:16 am |
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| Dear Dr Paul You have skipped correcting my answer.Can you please correct it.Awaiting to see the correction thanks seema Your answer has not been missed - it is not your turn yet |
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Posted by PAUL A. Sun Jan 11, 2009 12:42 pm |
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| Sir, Kindly clarify my query? Can a women who has not completed her family be offered definitive sugery for stress incontinence? thanks. Yes, they can but plans for future pregnancies have to be taken into account in deciding the best procedure and impact on mode of delivery should be discussed. If you were 30, had 2 children but wanted 5 and suffered from stress incontinence, will you accept wetting yourself for another 10 years? |
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Posted by PAUL A. Sun Jan 11, 2009 12:50 pm |
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| a thorough history should be obtained in elation to the duration and severity of symptoms. Ask if the problem is effecting her quality of life (1) in any way.Inquire about the use of continence pads.Inquire about associated problems such as urgency, nocturia to rule out the possibility detrusor overactivity (1) .Inquire about dysuria, frequency and hesitancy to rule out the posibility of UTI (1) . Take a detailed medical history to rule out any respiratory prblem leading to persistent coughing HEALTHY since it can make her problem worse.Also inquire about bowel habits to rule out constipation. Personal history regarding smoking and alcohol intake should be looked into.Inquire about her daily fluid intake (1) in terms of tea, coffee, and fizzy drinks since excess of these can make her problem worse. As we know her parity, establish whether these were normal deliveries or caesarian sections since vaginal deliveries deliveries tend to weaken the pelvic floor ? family complete . Clinical examination should entail noting the BMI since a high BMI makes stress incontinence worse. Vaginal examination should include resting pelvic tone, the ability of the patient to carry out a pelvic contraction. During the examination, the patient should be asked to cough to see if there is any leakage of urine. A per rectal examination should assess anal tone and note the presence of any hard stools.The presence of a cystocele or a rectocele should be noticed (1) ? abdominal examination. Initial investigations include, urinlysis to rule out UTI (1) dipstix , ramdon blood sugar to rule out diabetes mellitis and urodynamic investigations to establish the diagnosis not necessary . If conservative Mx fails, the other options remaining are surgical and non surgical. surgical options are colpsuspension which is considered as the gold standard (1) how successful? EVALUATE . Other options include TVT (1) or TOT.Colposuspension has a high sucess rateof 90% at 1 year and 80 % at five years (1) . It is associated with denovo detrusor instability , voiding difficulty not necessary .with TVT andTOT have similar sucess rates what are the success rates? Are 5 year data available for TOT? . Although they have problems associated with mesh insertion such as erosion, infection, bladder and urethral damage not necessary – are the problems associated with TVT similar to TOT? . If surgery is not an option than other treatment options include external meatus plugs, urethral plugs etc.they have a high sucess rate but are associated with complications such as infection, cuff erosion, damage to urethra. You should address every procedure separately otherwise you lose marks and make mistakes. TVT – local anaesthesia, day case, more cost-effective |
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Posted by PAUL A. Sun Jan 11, 2009 01:16 pm |
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| HISTORY a) Urinary incontinence is a common problem which can affect a woman, both, socially and psychologically affecting her quality of life. Urinary Incontinence maybe due to various causes and value of a detailed history cannot be overlooked. Ask regarding any associated symptoms although difficult to make diagnosis on symptoms alone waste of time & space . Urodynamic stress incontinence is classically associated with involuntary leakage on effort or on coughing and straining as this woman presented. Detrusor overactivity is classically associated with frequency, urgency, urge incontinence, nocturia and nocturnal enuresis you are not answering the question. You have not told the examiner what you will ask in your history. . Continuous dribbling or post micturition dribbling are more likely to be associated with neurological disorders, overflow, urethral diverticula or a fistula. Ask regarding symptoms of urinary tract infection like frequency, dysuria or haematuria (1) . Bladder pain (1) may suggest interstitial cystitis. Precipitating conditions for urodynamic stress incontinence like chronic cough HEALTHY and constipation should be enquired. Ask regarding fluid and caffeine intake (1) . Note her parity and previous pregnancy outcomes and her desires regarding future fertility (1) . Is she using any contraception as oral contraceptive pills may need to be discontinued 6 weeks prior to any major surgery. History of any chronic medical illnesses is also taken to assess her suitability for anaesthesia and any major surgery READ THE QUESTION - healthy . Enquiry should be made regarding any voiding dysfunction will the woman know if she has voiding dysfunction? You need to ask about symptoms – poor stream, hesitancy as some surgical procedures may aggravate any pre-existing voiding dysfunction. Ask about associated faecal incontinence (1) . Finally, ask regarding severity of symptoms, the presence of prolapse prolapse symptoms and previous surgeries if any, and the effect of previous treatments (1) .This will help in deciding the most appropriate treatment option. Woman\'s wishes and choice should be taken into consideration. Written information and contact details of support groups should be provided waste of time / space – you were asked about Hx – you will lose marks because you will run out of time . CLINICAL EXAMINATION b) I will assess her body mass index from height and weight. Objective confirmation of involuntary leakage of urine per urethra or coughing and straining is made. Look for the presence and severity of any associated prolapse (1) . A fistula, if large, may be seen on speculum examination. will you examine her abdomen??? INVESTIGATION c) I will ask the woman to complete a bladder diary (1) to quantify urinary frequency and incontinence episodes. She is asked to complete a 3 day period to allow variation in day-to-day activity such as, both, working and leisure days. Urine dipstick tests to detect blood, glucose, protein leucocytes and nitrites is done (1) . Multichannel filling and voiding cystometry, ambulatory urodynamics and videourodynamics are recommended before surgical treatment not recommended – see NICE guidelines / NOTES . EVALUATION TREATMENT OPTIONS d) Treatment can be pharmacological or surgical. The most appropriate treatment option would depend on the the severity of symptoms. The presence of prolapse read the question – NORMAL clinical examination , previous surgery, mobility of bladder neck, likelihood of voiding dysfunction, suitability for major surgery read the question – healthy 40 year old and available surgical expertise. The womans child bearing wishes should be considered. Duloxtine, a selective serotonin and noradrenaline re-uptake inhibitor is associated with a significant reduction in incontinence episodes and improvement in quality of life. It is associated with dry mouth decreased libido and anorgasmia as major side-effects. It is associated with withdrawal reaction and hence, dose should be gradually tapered over a 2 week period. Long term data on duloxetine is not available. It should not routinely be used as a first or second line treatment for stress urinary incontinence so why have you written it first? . Maybe offered as an alternative to surgical treatment. The woman should be counselled about adverse effects You are not answering the question. What are the options and what is their value? . The first operative procedure offers the best chance of cure, therefore, select the most appropriate procedure for each patient. As a primary procedure, Burch colposuspension remains the gold standard (1) for surgical treatment with success rate of 80-90% for first year ? 5 years?? . Open colposuspension is more successful than laparoscopic procedure. It is associated with 10-12% risk of voiding dysfunction. There is also increased incidence of destrusor overreactivity and enterocele and rectocele formation not necessary . Surgical expertise is widely available. Laparoscopic colposuspension has lower success rate (1) with increased risk of urinary tract injury and expertise is not widely available. The Marshall-Marchetti Krantz procedure has similar short term success rate to the Burch colposuspension but carries the risk of ostetis pubis which is diffcult to treat. Sling procedures such as stamey operation have poor long term success rate but also low morbidity. The tension free vaginal tape (TVT) is just as effective as Burch colposuspension after 1 and 5 years (1) day case, local anaesthetic, more cost-effective . There is 8% risk of bladder injury. Long term risk of tape erosion is not known. Has shorter hospital stay compared to colposuspension . Prolapse surgery may be undertaken concomitantly. Ideal for women with poor anaesthetic/surgical risk profile do these apply to the woman in question? YOU WOULD HAVE RUN OUT OF SPACE HERE . Transobturator is a new procedure with similar success rate to TVT. Long term outcome data not available. Anterior colporrhaphy with bladder neck buttress has low complication rate but long term cure rate is also low. For surgery after previously failed procedure-TVT is suitable after failed colposuspension . Other procedures include collagen injection, artificial sphincters, neourethras and urinary diversion. They should be reserved for expert surgeons and intractable incontinence. |
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Posted by PAUL A. Sun Jan 11, 2009 01:23 pm |
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| A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks] parity and mode of del time duration after last delivery/is she pregnant now? duration of problem/fluid intake/caffiene intake frequency nocturia incomplete emptying, urgency frequency of incontinace and efect on quality of life mass per vagina/dragging sensation sexually active? other medical problems especially connective tissue disorders The examiner has taken the time to set the question in complete sentences. The lease you can do is return the favour and write in complete sentences. This is a post-graduate exam (b) What information would you obtain from the clinical examination [2 marks] P/A to r/0 mass per abdo P/s in left lateral position to perform POP Q score to r/o prolapse, bladder neck mobility on straining to assess the strength of pelvic floor (c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks] MSU dailty fuid intake diary bladder diary Urodynamics (d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence. Evaluate the subsequent treatment options [6 marks]. taking her age in to consideration, options would be supportive management can wait and watch for some more time if it is not affecting the quality of life which is rare in a 40 year old with future clinic apt to kno the progress surgical methods Burch colpo suspension pros 80 -90 % success in first year 70 % patient satisfaction rate permanent solution no dysparaunia cons needs laparotomy about 10.3 voiding problems post surgery prolonged poeration time tot/tvt pros no laparotomy can be performed as a day case 1 st year success rate comparable to colposuspension sooner recovery con dysparaunia tape erosion /infection injury to bladder & ureters vioding difficulties comparable to colposuspension laparoscopic colposuspension prso aviods laparotomy cons longers operating time needs expertise ileo sacral suspension(laparoscopic) long op tme no long time studies available SEE COMMENTS ABOVE |
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Posted by Ahmad A. Sun Jan 11, 2009 03:06 pm |
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| Sorry Paul, I think my answer was skipped, is it true? thanks. |
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Posted by Maayka .. Mon Jan 12, 2009 12:39 am |
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| a) She should be asked about other urinary symptoms to elicit if there is a mixed picture of overactive bladder and stress incontinence – questions about frequency, nocturia, urgency and urge incontinence should be asked. Also I wish to find out if she has voiding dysfunction – strangury, postmicturtion dribbling, poor stream or sensation of incomplete emptying. Important also is the history of coitarchal incontinence and of stool and flatus and asking about possible vaginal wall prolapse symptoms. She should be asked specifically about the effect of her symptoms on quality of life – need for pads, certain types of clothing and if there is diet restrictions imposed by her. Is there a use of anxiolytics and diuretics by the patient? Her diet should be looked into especially w.r.t. use of caffeine and total fluid intake. If she is a smoker and alcohol user, this would influence her management. Her past obstetric history is relevant if she had a prolonged second stage and episiotomy, especially greater than third degree laceration repaired. Her future reproductive ambitions and sexual function would be useful in planning her treatment. It is important to inquire about earlier surgical attempts to treat her symptoms, as it will influence subsequent chosen options. b) Her measurement of BMI and abdominal/ pelvic examination will be done. The latter to determine if there are any abdominal masses and to elicit stress incontinence with a cough reflex. A check of pelvic organ prolapse e.g. for a cystocele will be useful in deciding subsequent treatment. c) An MSU for ruling out urinary tract infections and a urinalysis to check for protein/ nitrites immediately. An outpatient bladder ultrasound to check residual volume (postvoiding). A bladder diary for 3 to 5 days can be done. d) Treatment options for this patient are either medical or surgical now. Duloxetine, an SNRI, can be used while she is awaiting surgical options or if she chose this while planning / deciding if future pregnancy desirous. It helps by increasing the urethral sphincter mechanism control. Surgical options will be influenced by the presence of pelvic organ prolapse. If there is none then Burch Colposuspension can be done under general anaethestic either abdominally or lapascopically and it has a success rate (continence) of 85 – 90% at 1 yr and 70% at 5 yrs. Slings such as the transvaginal tape (TVT) Can be done under local aneasthetic in same day surgery and it has a success rate of 85- 80% at 5yrs. It is a shorter procedure than Burchcolposuspension with lower postop morbidity. Anterior colporrhapy can be done if a cystocele is also present but success rates not as great as the above 2 procedures. Transobturator tape is another option but increase risk of bladder injury vs. TVT. Also, techniques like needle suspension techniques which involve injecting a synthetic material on either side of the proximal urethra has lower success rates at 1 yr vs. the previous techniques |
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Posted by PAUL A. Mon Jan 12, 2009 01:46 am |
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| Sorry we missed your answer I would like to have a detailed history of her previous difficult deliveries, or using forceps specially midcavity. Also, I would ask for any vaginal tears especially of third or fourth degree tears ? family complete may cause faecal incontinence with urinary incontinence. Also, if there is any anterior vaginal tears and/or urethral lacerations. I would ask about the duration of her symptoms and if there is direct relation between the deliveries or not, also the dates of her birth specially with recent delivery. Also, if it recur with subsequent delivery. I would ask about her general habits of smoking, alcohol, fluids and coffee taking (1) . I would ask about the other symptoms of possible urinary tract infection (UTI) like frequency or burning micturition (1) and other symptoms of detrusor overactivity like urge incontninence, nocturi, frequency. I (1) would ask if these symptoms affecting her social life (1) quality of life or if she in need for extra precautions during social events or her regular exercise. ? prolapse symptoms Clinical examination should tell us about the abdominal examination of possible palpable masses (1) . Also, the local examination of vulval irritation because of longstanding leaking and possible vulval or vaginal ulcerations. Pelvic examination of pelvic area using sims and or standing position with evaluation of the degree of anterior or posterior vaginal wall prolapse (1) . Urine sample, microscobical and midstream for culture and sensitivity should be asked initially to rule out UTI (1) . Also, I would recommend to have Flowcystometry to rule out other possible problem like over activity and to confirm urodynamic stress incontinence (USI). not necessary in initial investigation The possible treatment option in case of failure of the conservative management either medical or surgical. Medical treatment like using Detrusitol What is detrusitio? Used for urodynamic stress incontinence?? (-2) as, it may improve the condition by 50-60%. On the other hand the surgical procedure may be offered in case of failure of other options. There are many surgical procedures could be offered. However, with healthy woman, the best 2 options either colposuspension or sling procedures. Burch coposuspension is one of the successful procedure may give up to85-90% continent rat after 3-5 years (1) . Also, it may help correction of the anterior vaginal wall prolapse (cystocele) does this woman have a prolapse? Question says clinical examination NORMAL . However, it may cause entrocele (10-12%0, de novo detrusor overactivity by 10-15% of cases and 8-10% of cases may suffer of urinary retention not necessary – not asked to critically evaluate . On the other hand the less invasive procedures like transvaginal tape (TVT), Trans obturator tape (TOT) and Spark these should be addressed separately . Most of these procedures which of them do not? may give more than 85% of continent rate. Local or regional anaethesia may be used for the procedures (1) . Also, it may cause urinary retention or urethral or bladder trauma not necessary . Patients\' information leaflet should be given to her and briefly discussing the variable options not answering the question – you were not asked to treat / manage the woman. You were asked to EVALUATE the options . |
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Posted by PAUL A. Mon Jan 12, 2009 01:54 am |
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| a) She should be asked about other urinary symptoms to elicit if there is a mixed picture of overactive bladder and stress incontinence – questions about frequency, nocturia, urgency and urge incontinence should be asked (1) . Also I wish to find out if she has voiding dysfunction – strangury, postmicturtion dribbling, poor stream or sensation of incomplete emptying (1) . Important also is the history of coitarchal incontinence and of stool and flatus (1) and asking about possible vaginal wall prolapse symptoms (1) . She should be asked specifically about the effect of her symptoms on quality of life (1) – need for pads, certain types of clothing and if there is diet restrictions imposed by her. Is there a use of anxiolytics and diuretics by the patient? do not ask the examiner questions Her diet should be looked into especially w.r.t. use of caffeine and total fluid intake (1) . If she is a smoker and alcohol user, this would influence her management. Her past obstetric history is relevant if she had a prolonged second stage and episiotomy, especially greater than third degree laceration repaired. Her future reproductive ambitions (1) and sexual function would be useful in planning her treatment. It is important to inquire about earlier surgical attempts (1) to treat her symptoms, as it will influence subsequent chosen options. b) Her measurement of BMI and abdominal/ pelvic examination will be done. The latter to determine if there are any abdominal masses (1) and to elicit stress incontinence with a cough reflex. A check of pelvic organ prolapse e.g. for a cystocele (1) will be useful in deciding subsequent treatment. c) An MSU for ruling out urinary tract infections and a urinalysis (1) to check for protein/ nitrites immediately. An outpatient bladder ultrasound to check residual volume (postvoiding). A bladder diary for 3 to 5 days can be done (1) . d) Treatment options for this patient are either medical or surgical now. Duloxetine, an SNRI, can be used while she is awaiting surgical options or if she chose this while planning / deciding if future pregnancy desirous. It helps by increasing the urethral sphincter mechanism control. Surgical options will be influenced by the presence of pelvic organ prolapse read the question – examination is NORMAL . If there is none then Burch Colposuspension can be done under general anaethestic either abdominally or lapascopically and it has a success rate (continence) of 85 – 90% at 1 yr and 70% at 5 yrs (1) is success rate for open colpo the same as for laparoscopic??? . Slings such as the transvaginal tape (TVT) Can be done under local aneasthetic in same day surgery (1) and it has a success rate of 85- 80% at 5yrs (1) . It is a shorter procedure than Burchcolposuspension with lower postop morbidity. Anterior colporrhapy can be done if a cystocele is also present normal examination but success rates not as great as the above 2 procedures. Transobturator tape is another option but increase risk of bladder injury vs. TVT ? success rate?? EVALUATE . Also, techniques like needle suspension techniques which involve injecting a synthetic material on either side of the proximal urethra is this needle suspension? has lower success rates at 1 yr vs. the previous techniques |
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Posted by PAUL A. Mon Jan 12, 2009 01:58 am |
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| A good candidate should (a) History • Effects of symptoms on quality of life (1) • Other urinary symptoms: urgency, urge incontinence, frequency and nocturia. Symptoms of voiding dysfunction – dribbling, hesitancy, poor stream, straining to void (1) • Symptoms of UTI dysuria / frequency / haematuria (1) • Presence of bladder pain & prolapse symptoms (1) • If multiple symptoms, identify which symptom is most troublesome (1) • Bowel symptoms – constipation, incontinence of faeces / flatus (1) • Past obstetric Hx including date of last delivery & Reproductive intentions (1) • Fluid intake including caffeine and alcohol (1) • Previous treatment for incontinence including surgery (1) • Social history including mobility, dexterity and access to toilets; smoking (1) (b) Examination (2) • BMI • Abdominal and pelvic examination: abdomino-pelvic mass, palpable bladder • Presence of prolapse • Demonstrate stress incontinence with moderately full bladder (c) Investigations (2) • Know value of urinary diary for a minimum of 3 days • Urine dipstix for protein / nitrite / leucocytes / blood / glucose • MSU if symptomatic of UTI or positive dipstix (d) Treatment options • Know the value of retro-pubic mid-urethral bottom-up tape procedures (TVT) – success rate 85 - 90% over 5 years and can be undertaken as day-case under local anaesthetic. Cost-effective in comparison to colposuspension (2) • Colposuspension (open) is an alternative with similar success rates to TVT and more long-term data available (2) • Retro-pubic ‘top-down’ procedures such as the trans-obturator tape may be used but women should be informed of the absence of long-term data. Short-term outcomes similar to TVT (1) • Laparoscopic colposuspension is not recommended while peri-urethral bulking agents require multiple injections and their efficacy diminishes with time and therefore may not be appropriate for young women (1) |
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Posted by PAUL A. Mon Jan 12, 2009 02:01 am |
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| A good candidate should (a) History • Effects of symptoms on quality of life (1) • Other urinary symptoms: urgency, urge incontinence, frequency and nocturia. Symptoms of voiding dysfunction – dribbling, hesitancy, poor stream, straining to void (1) • Symptoms of UTI dysuria / frequency / haematuria (1) • Presence of bladder pain & prolapse symptoms (1) • If multiple symptoms, identify which symptom is most troublesome (1) • Bowel symptoms – constipation, incontinence of faeces / flatus (1) • Past obstetric Hx including date of last delivery & Reproductive intentions (1) • Fluid intake including caffeine and alcohol (1) • Previous treatment for incontinence including surgery (1) • Social history including mobility, dexterity and access to toilets; smoking (1) (b) Examination (2) • BMI • Abdominal and pelvic examination: abdomino-pelvic mass, palpable bladder • Presence of prolapse • Demonstrate stress incontinence with moderately full bladder (c) Investigations (2) • Know value of urinary diary for a minimum of 3 days • Urine dipstix for protein / nitrite / leucocytes / blood / glucose • MSU if symptomatic of UTI or positive dipstix (d) Treatment options • Know the value of retro-pubic mid-urethral bottom-up tape procedures (TVT) – success rate 85 - 90% over 5 years and can be undertaken as day-case under local anaesthetic. Cost-effective in comparison to colposuspension (2) • Colposuspension (open) is an alternative with similar success rates to TVT and more long-term data available (2) • Retro-pubic ‘top-down’ procedures such as the trans-obturator tape may be used but women should be informed of the absence of long-term data. Short-term outcomes similar to TVT (1) • Laparoscopic colposuspension is not recommended while peri-urethral bulking agents require multiple injections and their efficacy diminishes with time and therefore may not be appropriate for young women (1) |
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Posted by PAUL A. Mon May 7, 2012 01:58 am |
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