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Essay 297 - Urinary incontinence

Essay 297 - Urinary incontinence Posted by PAUL A.
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].
Posted by Johnson  O.
A/
Failed medical treatment is an indication for specialist refeeral. Treatment can fail because of wrong diagnosis. Woman may have detrusor overactivity, stres or mixed incontinence. The symptoms may overlap. Therefore, where GP is not sure of diagnosis, it is appropriate to refer the woman for investigation and appropriate treatment.
Incontinence may be as a complication of medical or surgical treatment. Incontinence following pelvic surgery like hysterectomy, incontinence surgery or prolapse repair require urgent specialist referral, because it may be due to urinary tract fistula. Also, radiotherapy can cause fistula.
Recurrent infection causing incontinence should be referred for specialist care. Women themselves may request for referral to specialist unit, most especially if the symptoms is affecting quality of life and want answers and urgent specialist care.
B/
Treatment can be conservative, medical, use of device or surgery. Conservative treatment would be recommended as initial treatment. I would encourage obessed woman to lose weight, reduce cigarette smoking and reduction in fluid intake. Any provocative factors like chest infection or constipation would be treated. Avoidance of lifting heavy objects. Success rate of this measures is about 40-50%.
Supervised Pelvic floor exercise would be offered to all women with stress incontinence, except the frail and debilitating women who would not be able to perform it. I would offer it for about 6months, and its success is about 50 to 60%.
I would offer medical treatment for those who are unfit or doesn\'t want surgery. Serotonin and Noradrenalin reuptake inihibitor like Duloxetin may be effective.
I would offer Trans Vagina tape[TVT] to women who are fit for surgery. it is a sling procedure with 85% cure rate in 1st year, but becuase it is a new method, long term effect is not know yet. There are risk of bladder perforation, erosion and detrusor overactivity.
Burch colposuspension is another option, with a similar success rate as TVT[85%], with 70% 5years cyre rate. The side effect include De-nove detrusor over activity, bladder injury.
Marshal Markhet Khants is also a retropubic surgery but I would not recommend it because of risk of oseitis pubis.
Anterior vagina wall has less complications, with less risk of catheterisation, but the success rate is just about 66% in 1st year reducing to about 35% by 5years. Therefore in long term, it is not an effective surgery. It is useful for women with cystocele.
If a woman has had previous surgery that failed I would recommend Bulking agent like collagen or silicone, injected to the paraurethral area. less effective, about 30%.
Other method include artificial urethra spincter.
Devices like continence pad or urethra plug would be offered to those women with failed previous surgery or unfit for surgery. The success mainly depend on usage as it is not curative. There is increase risk of urinary tract infection.
I would provide written information leaflet, to enable woman make a well informed decision. Proper documentation of management plan.

Posted by Leen K.
LEEN
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].

(a) Women with stress or mixed (urge and stress) urinary incontinence, are usually advised to lose weight as well as make lifestyle changes (such as reduce caffeine intake) and community physiotherapist can teach them pelvic floor exercises. However, if her symptoms are not improved; or has a significant impact on her quality of life and is getting worse, then hospital assessment should be sought. Women with previous incontinence surgery should also be referred to a urogynaecologist.
Women who also complains of concurrent prolapse should also be referred to hospital, as she may need treatment for it as well as for her incontinence.
Women with urge incontinence, who are not responding or tolerating bladder retraining, or first line pharmacological treatment should be assessed by a urogynaecologist.
It is also important, if the GP suspects that her incontinence might require surgical treatment, such as urinary tract fistula, the patient should be reviewed in hospital.

(b) Lifestyle changes such as weight loss (if obese) and cutting down on caffeine; and together with pelvic floor exercises may help improve stress urinary incontinence in approximately 50% of women.

There are a few different surgical options, and the type of surgery may depend on whether there is marked urethral sphincter weakness, previous history of incontinence surgery or whether the woman has risk factors that increases her general anaesthetic(GA) risk, as well as patients\' choice.

Burch colposuspension(BC) is the gold standard, due to lots of longterm data; and is suitable for women with urethral sphincter weakness. It improved incontinence in 85-90% of women by 1 year, but is associated with a risk of iatrogenic detrusor instability. It also requires the patient to undergo a GA. Marshall Marchetti Kranz procedure has also similar incontinence rate to burch colposuspension, but is not performed as often now, due to an associated adverse risk of osteitis pubis.

Tape procedures such as Tensionfree vaginal tape(TVT) lifts the midurethra, and is suitable in patients who has previous failed incontinence surgery (such as burch colposuspension). Success rates are comparable to BC, 85-90%, but has a higher bladder injury risk of 8%. It is also associated with a risk of transient detrusor instability and voiding dysfunction. It has the advantage of being done under local or regional anaesthetic making it suitable for patients with a higher GA risk. Trans obturator tape (TOT) and TVT-obturator are newer and seems to have similar success rates to TVT, but require long term data for comparison.

Anterior colporrhaphy has poor success rates for curing incontinence, and majority(70%) of improvement of continence tends to regress within a year. It is associated with a lower morbidity and complication rate compared to the above procedures.

Urethral buttress and neo-urethra has success rates of approximately 70%, but tends to require repeat procedures every few years. However, the morbidity associated with these procedures are much lower.

Duloxetine can be used if surgery is not suitable or if the patient refuses surgery. It has lots of side effects, including dry eyes and mouth, and a success rate of approximately 60-70%.
Posted by Ajith S.
A-
Specialist referrals may need in following conditions –1.True incontinence following, surgery, radiotherapy, obstetric injuries and other genital tract trauma with true incontinence example straddle injuries where there is minimal intervention that community staff can do.2.Failed medical management of Urge incontinence specially with mixed stress incontinence where urodynamic studies and proper diagnosis need for further management. .3 failed conservative management of stress incontinence with poor quality of life scores.4Medical and surgical diseases associated incontinence where failed change of medication and conservative managements ex Spinal cord lesions and Multiple sclerosis.5 Any patients with minimal response to conservative management like weight reduction, pelvic floor exercise, life style modification like cut down caffeinated drinks where patient is not happy that seek specialist services.6 Patient who have symptoms suggestive of urogenital malignancies where urgent and appropriate investigation-ex asymptomatic haematuria 7. Failed or complications following previous incontinence surgical procedures-Ex –Sparc tape erosions
B-
Urinary stress incontinence need to be confirmed by Urodynamic studies as Genuine stress incontinence(GSI) but conservative management can be undertaken without urodynamic studies. Need to explore and examine for symptoms which may need surgical repair that will relieve Stress incontinence ex complete procedentia
Options available for GSI are -1 Conservative management Iwill advice her that improtence of conservative management lie weight reduction , pelvic floor physiotherapy with dedicated pelvic floor physiotherapist where supervise is essential in most of patient for correct technique where success rate over 50% but need to continue life long , life style modifications like stop smoking, avoid excess drinking of water at night ,management of chronic constipations with change of diet and stool softening agents ,change of medications example like Angiotensing converting enzyme inhibitors where chronic cough present as side effects of medication. Associated medical problems need to be controlled well like Congestive Cardiac failure, Chronic Obstructive Airway disease with recurrent chest infections –may need appropriate medical specialist review. Conservative management is paramount importance for initial management for stress incontinence where over 50%can have cure. I will advice to try conservative management at least 6/12 before surgical procedures.Contineance Sister can educate ongoing care for these patients.
2 .Medical management where pt is waiting for surgery or does not keen on surgery ,SNRI (Serotonin Noradrenalin Reuptake Inhibitor)–Duxoletine is effective drug that stress incontinence can be controlled for short term (12/weeks), 40mg need to date twice a day ,has side effects of and cannot take with other antidepressants like SSRI.
3. Surgical management –Depend on whether pt has any other anterior vaginal wall prolapsed or uro- genital prolapsed .If she has large anterior wall defect pt may have simple surgery like anterior repair with bladder buttressing suture .which has 30% cure rate in over 5 years Simple uncomplicated GSI can be nearly cured with TVT-(Trans Vaginal Tension free Tape) procedure where proline –synthetic knitted mesh apply across the middle part of urethra under regional anaesthesia as day procedure and has success rate of 90 after 1 year and 70% over 5 years unfortunately long term data is lacking at this stage .This procedure has complication tape erosions and inherit risk of bladder perforation -10% which can be check immediately or during procedure .As like any incontinence surgery TVT can develop den ova bladder overactivity and voiding difficulty.
I will explained other Surgical procedures to Patient r like–Burch colposuspension gold standard at this sate –where proximal urethra and bladder neck elevation under open or laparoscopic procedure, short term success rate is similar to TVT but long term data is available ,this procedure is preserved for pt who have failed simple procedures like TVT .Burch colposuspention has similar rate of complications like denova detrusor overactivity and voiding difficulties . other surgical procedure which I will discourage her to undergo is MMK- Marshal Markhet Khant procedure which distal urethra anchored to pubic bone(retro pubic ) has rare oseitis pubis complication and alternative procedures have similar success rate with less complications.
4. Patient who had multiple surgeries and still incontinent i will explained Para urethral bulking agents where Collagen and other synthetic material –Silicon inject in to proximal para urethral area, success rate is less than 30% may need to repeat the procedure. Other options like urethral plug is not gain wide popularity and have high urinary tract infection risks, artificial sphincter and other experimental procedures currently not freely available. I will explains her all the available options and give her written self explained documents.
Posted by H H.
Patients are referred to hospital for better facilities of investigations and treatment.patients may need urodynamic investigations(UDS) if she had urinary stress incontinence which was being treated in community with pelvic floor excercises but this failed and so will need surgery.According to NICE guidelines UDS needed first to exclude associated detrusor instability or voiding dysfunction. Patients who had detrusor instability and being treated with bladder drill at home without success might benfit of the proceder being done on an in patient basis but it will be more costy.Patients with incontinence associated with hematuria might need admission foe cystoscopy ,but this can be done on day surgery unit.Patients who had associated urinary tract infection with incontinence will need specialist hospital intervention.A patient with uncontrolled diabetes associated with urgency incontinence will need hospital admission and intervention to control her diabetes.Patient with painful micturition,urgency incontinence and hematuria long standing will need cystoscopy to exclude interstitial cystitis( glomerulation and Hunner ulcer), or stone. Patient referral for urinary incontinence are low ,this might be due to patient not seeking medical advice or the general practitioner treating her for another reason.Written information ,teaching GPs regarding incontinence and directions to patient to whom she should seek will icrease such referrals.

Conservative measures should be used first.Pelvic floor exercises to increase pelvic muscle tone have success rate of 27-67% ,but when stopped recurrence of symptoms occur.Vaginal cones and pelvic faradism will help to increase muscle tone but studies showed insignificant effect.Mechanical devices can be used but associated with trauma and bleeding.They can be used during acts of exersion eg playing squash.
Medical treatment using Dulexetine which inhibit the reuptake of serotonin and nore epinephrine increasing the uretheral muscle tone, will help in some patients but this limited by its side effects as nausea, dry mouth and anorgasmia.
UDS should be done before embarking on surgical treatment after failure of conservative treatment. The surgical procedure recommended by NICE is the Tension free vaginal tape(TVT) ,being a simple procedure ,can be done under local anesthesia ,even on an out patient measure and gived success rate equal to open Burch colposusspension (80-90% cure rate even after 5 years).It is associated with less detrusor instability and voiding dysfunction than Burch but there is risk of bladder perforation 8% and tape erosion.Another sling procedure like TVT but still studies being gathered about it is the Transobturator tension free tape is associated with less bladder injury than the TVT but more risk of erosion.
Laparoscopic coposuspension give less success rate than open Burch and will need more expertise
Suburetheral implants are easy to do with low complications rate but also low success rate.Other operations that were used for stress incontinence but failed to continue in its treatment due complications or low cure rate include ,Marshal Marchette operation and anterior vaginal wall repair with Kelly,s suture.

Posted by robina K.
(A) Majority of the women with urinary incontinence are managed at primary health care centre , after taking detailed history, to determine the possible causes of incontinence, examination of the women to rule out uterovaginal prolapse and pelvic masses and investigations like MSU to rule out UTIs , frequency volume charts to determine intake and out put record and urinary diary over a week for frequency and volume of urine voided.There are clear referral pathways at primary care and the following women should be referred for specialist management.
Stess incontinence associated with UTIs wich are resistant to oral antibiotics, recurrent UTIs or associated hematuria should be referred.
Incontinence associated with voiding dysfunction , uterovaginal prolapse , pelvic masses and genital tract malignancy also needs referral.
Women with mixed incontinence like frequency, urgency , urge incontinence, nocturia ( after excluding diabetes and diuretics intake) should be also be referred.
Failed treatment at GP level wheather life style modification , pelvic floor exercises and medical treatment should be referred for further investigation.
Previous failed incontinent surgery should immediately be referred.
If woman wishes to be seen by a specialist.
Incontinence could be due to fistula with symtoms of continous leaking confirmed by three swab test is referred for evaluation to rule out bladder carcinoma or due to radiation for cervical carcinoma.

(B) Treatment options depend on the age of the women, other types of incontinence , voiding dysfunction previous failed conservative and medical treatment at primary care , previous failed surgical treatment, health of the women and co morbidities, associated uterovaginal prolapse and avaiability of experties.
I will review her referral file for relevent points from the history, examination , investigations and treatment offered at GP level . I will discuss her sympoms , if it suggests stress incontinence , I will offer a pelvic examination to confirm it objectively and also to rule out prolapse, pel;vic masse . I will examine tone of the pelvic floor muscles , the perineal sensations and mobility of urethra .The treatment options for stress incontinence are life style modification like decreasing cofee, tea, alcohol, change of clothes, change in timings of diuretics if she is on and treatment of diabetes , chest infection and constipation. Pelvic floor exercise for 15-20 weeks improves the quality of life by decreasing incontinence in 27-67% of women .simple , non invasive and cheap but needs motivation and referral to physiotherapist.These treatments are provided if not recieved at primary level.
Medical treatment for stress incontinence includes SNRI Duloxetine 40 mg twicw daily for 12 weeks and alpha adrenergic agonist phenyle propanolamine.both increases sphincter muscle tone in about 80% at one year but efficacy decreases after stoppping .

Before considering surgical treatment urodynanic studies are offered to confirm urodynamic stress incontinence.
Surgical options include colposuspention procedures. The aim is to elevate proximal urethra in to thw abdomen .these are Burch colposuspention when the para urethral tissue is elevated to ipsilateral ileopectineal ligament. Can be performed via laparotomy or laparoscopy. Cure rate at one year is 85-90% and 70% at five years.It can cure mild cystocele but causes denovo detrrusor overactivity in 17%, voiding dysfuntion in 10% and concomitant enterocele in 14%.
MMK procedure is not recommended due to 2-3 % risk of osteitis pubis.

Sling procedures includes TVT and TOT .Mersiline taps are applied at mid urethra under local or regional anesthesia. Useful in stress incontinence due to intrinsic muscle weekness.Cure rate at one and five years are similar 85-80% and 80% respectively.Risk of denovo detrusor overactivity is 10%, voiding problems is 4% and ureteric injury is 9%.
Suitable for previous failed surgery and very frail women.
Anterior repair may be help full if there is urethral kinking but it may worsen the symptoms by un masking underline occult stress incontinence.
Other options are periurethral bulking agents, continent devices, urethral plugs .Rarely neourethra formation , artificial sphinter or urinary diversion may be needed
I will provide her with informations about support groups like British INCONTINENT SOCIETY.
Posted by Shalini  M.
a)Microscopic hematuria in a lady more than 50 years and persistent and recurrent UTI in more than 40 years as also any visible hematuria should be seen by a specialist to rule out any malignancy. a suspected pelvic mass arising from the pelvis as also symptomatic prolapse eaching at or below the introitus needs hospital referral as causative pathology has to be treated.A palpable bladder after voiding on pelvic examination could suggest a bladder mass and needs specialist intervention.Also other conditions like persisting bladder and uretheral pain,associated fecal incontinence,suspected neurological disease needs hospital referral for multidisciplinary care.Any suspicion of a urogenital fistulae,previous incontinence repair,previos cancer surgery or pelvic irradiation also need Consultant evaluation in hospital.Any voiding difficulty needs detailed evaluation and thus hospital referral.
b)It is important to classify type of incontinence at the outset for clear management.Stress incontinence needs life-style modifications like weight reduction if BMI>30 as that would reduce the intraabdominal pressure causing incontinence.Also any excessive intake of caffenine and alcohol should be reduced as also the fluid intake.Supervised pelvic floor muscle training programme has been proven to be successful if correctly done 8 times three times a day for 3 months.If symptoms are not controlled by conservative measures then surgical procedures like retropubic mid-uretheral tape suspension using macroporous polypropylene meshes which have been proven to be 85% effective at 1 yearcan be offered.It has the advantage of being a day-case procedure with minimal morbidity.Drugs like duoloxetine should not be used as first line therapy and should onlu be used as an adjunct to surgery.Also Bursch colposuspension though a major surgery with more morbidity has success rates of 85% cure rate at 1 year post-procedure.Surgeries like Marshall-Marchetti-Krantz procedure are associated with oeteitis pubis and thus uncommon.Peri-uretheral bulking agents need repeated injections as there effect dcreases over time and thus only preferred for women in whom major surgery is to be avoided.In a lady with urge or mixed incontinence life style modifications go alongwith bladder retraining for 6 weeks.the lady is advised to postpone voiding to only fixed intervals and gradually increase the interval between voiding episodes tby 15 minutes.this has been found to be very successful.Also is symptoms are not improved by conservative measures then drugs like immediated release oxybutynin are found to be very effective in treatment.Side-effects like dry mouth,constipation are known and patient has to be counselled about continuing treatment.Also drugs like darefenacin,solefenacin,trospium can be used and have been found to be equally efficacious with less side-effects as they are selective for the m3 receptor.Sacral nerve stimulation can be offered to women who do not respond to medical management based on their response to percutaneous nerve stimulation results.this has been found to be very effective as other surgeries are very expensive.
Posted by nilasha A.
Symptomatic categorisation of the urinary incontinence based on the reports from the patient and history taking is sufficient to initiate a noninvasive treatment option at the primary health care level.Urinary incontinence is not life threatening but can be quite distressful for the patient,if the patient requests and is keen for the specialist referral her wishes must be respected.Indications for hospital referral can be divided into urgent and not urgent.Under the urgent referral category patients with microscopic haematuria and aged above 50,any recent or persisting UTI with haematuria aged 40 and above and any suspected malignant mass arising from the urinarytract.The above mentioned conditions with any form incontinence requires urgent referral to the hospital for specialist intervention.The other indications for specialist referral are any persisting bladder or urethral pain,associated faecal incontinence,suspected neurological disease,urogenital fistulas.If the patient has undergone any pelvic cancer surgeries,continence surgeries,radiation therapy also need the referral.Any incontinence associated palpable bladder on bimanual or abdominal examination after voiding should be referred to a specialist.Patients who did not respond to medical or pelvic floor exercises also require referral.


The treatment options can be conservative,medical and surgical.After assessing symptoms,associated factors like prolapse,medical conditions,previous continence surgeries,mobility of the bladder,surgeon expertise , fitness for the sugery the treatment should be initiated.Would start with the conservative treatment unless any contraindication,treat the underlying conditions if any like chronic cough,constipation,life style modifications like quitting smoking .50% of women actually benefit and may evade sugery.Pelvic floor exerceises are effective,27%-67% women benefit .It has to be done under physiotherapist supervision for 15-20 months.It needs motivation and will inform the patient about the recurrence after stopping the exercises.Mechanical devices bladder neck support prosthesis are an option if she has incontinence only during specific activites,success rates upto 87% have been noted after 12month usage.
Medical options like SSRI duloxetine 40mg twice daily can be used for short term while awaiting for surgery.It is associated with significant reduction of incontinence and also psychological impact with improvement in quality of life.Inform her that it cannot be used as first line treatment.Explain to her tthat side effects are significant like headache,nausea,decreased libido,dry mouth,and the drug cannot be stopped abruptly due to withdrawal effects.It has to be weaned over 2 weeks
Every patient contemplating surgery should be offered physiotherapy unless contraindicated.Surgery has to be preceded by urodynamic studies.Retropubic surgeries like Burch colposuspension is the gold standard surgery with 85%-90% continence rates by 1 year and 70% by 5 years.Complications are 10% voiding dysfunction,10% denovo detrusor instability,5-17% enterocele and rectocele formation.Sling operations like TVT are as effective as colposuspensions with 85 -90% at 5 years.the complications are bladder injury 8%.Anterior repairs are associated with high failure rates 27% compared to retropubic and sling procedures and hence routinely not done.Other supra pubic procedures like Marshall Marchetti Krantz procedure is not performed due to high failure rates and complications like osteitis pubis in 2.5% patients.Laparoscopic colposuspension is not routinely offered because requires highly skilled surgeon as it is associated with complications .
Would inform her other procedures like periurethral bulking agents,neo urethra,artficial sphicters have a role if other procedures fail.They have short term continence rate about 48% and require repeat surgeries.
Would give the patient written information , and would take her wish into consideration before initiating treatment.Inform her about the support groups like British Incontinence Society for further support
Posted by shipra K.
a)Urinary incontinence can be distressing problem and generally requires specialist care both for urodynamic studies and treatment. An urgent referral is required if symptoms are of constant dribbling i.e urinary tract fistula.,previous history of pelvic surgery,any previous surgery for incontinence ,any history of treatment of pelvic malignancy especially radiation therapy,if the patient has associated rectal incontinence also.If there is associated prolapse,any pelvic mass ,palpable bladder after voiding.a urine routine examination shows hematuria (painless)especially if the patient is above 40.If the symptoms do not improve after 3 months of pelvic floor exercises the patient needs referral to a specialist.
b)treatment options which i would offer ,first would be conservative management which includes pelvic floor exercises.this can be especially helpful in postpartum patients.Some women are benefited by contigard a vaginal tampoon which gives bladder neck support.A serotonin reuptake inhibitor and noradrelanine reuptake inhibitor duloxetine is available and has good results in urodynamic stress incontinence.a dose of 40 mg twice daily gives good results.If there is failure of conservative management surgery should be offered of burch colposuspension gives the best results(85% cure rates ).Laparoscopic colposuspension can also be done but increased chances of bladder injury.i would offer TVT that is transvaginal tape which has cure rate similar to burch colposuspension ie 85% and simpler procedure .Periurethal bulking agents can be offered which have lesser complications and lower success rates of just 45%. i will offer Anterior colporraphy in case there is associated prolapse though has lower cure rate(66%).Trans obturator tape is a recent technique and cure rates are not yet available.
Posted by shipra K.
A)Urinary incontinence can be a distressing problem and generally requires specialist care both for urodynamic investigations and treatment. An urgent specialist referral is required if the patient complains of constant dribbling i.e urinary tract fistula.specialist referral required if the problem developed after pelvic surgery,or if previous history of surgery for incontinence,history of treatment for pelvic malignancy especially radiation exposure to pelvis,any painless hematuria,history of rectal incontinence also.any pelvic mass on examination, bladder is palpable even after voiding.If there is recurrent urinary tract infection or patient suffering from diabetes again specialist referral would be required.Also if 3 months of pelvic floor exercises do not help in incontinence patient needs to referred.
B)treatment which i would offer would first be conservative which includes pelvic floor exercises for at least 3 months especially for postpartum patients.Contigaurd a vaginal tampoon device also helpful.DULOXETINE SSRI and noradrenaline reuptake inhibitor at a dose 40 mg twice daily is quite helpful.if conservative management fails or is unacceptable to the patient then surgery would be offered.Burch colposuspension gives excellant results with success rate of 85%.laparoscopic colposusspension to has similiar results but with higher chances of bladder injury.I would offer TVT ie transvaginal tape which is a much simpler procedure at the hands of an expert and success rates similar to burch colposuspension ie 85%.Periurethral bulking agents can be offered which have very few complications but also lower success rate of 46%.Anterior colporraphy can be offered in the presence of a prolapse of anterior vaginal wall but has lower success rate of just 66%.Marshal marchetti krantz procedure has now fallen out of use because of increased chances of osteitis pubis. Needle suspension like stamey and raz can be offered but have success rate of 70% with a higher chance of complications.
Posted by shipra K.
a)Urinary incontinence can be distressing problem and generally requires specialist care both for urodynamic studies and treatment. An urgent referral is required if symptoms are of constant dribbling i.e urinary tract fistula.,previous history of pelvic surgery,any previous surgery for incontinence ,any history of treatment of pelvic malignancy especially radiation therapy,if the patient has associated rectal incontinence also.If there is associated prolapse,any pelvic mass ,palpable bladder after voiding.a urine routine examination shows hematuria (painless)especially if the patient is above 40.If the symptoms do not improve after 3 months of pelvic floor exercises the patient needs referral to a specialist.
b)treatment options which i would offer ,first would be conservative management which includes pelvic floor exercises.this can be especially helpful in postpartum patients.Some women are benefited by contigard a vaginal tampoon which gives bladder neck support.A serotonin reuptake inhibitor and noradrelanine reuptake inhibitor duloxetine is available and has good results in urodynamic stress incontinence.a dose of 40 mg twice daily gives good results.If there is failure of conservative management surgery should be offered of burch colposuspension gives the best results(85% cure rates ).Laparoscopic colposuspension can also be done but increased chances of bladder injury.i would offer TVT that is transvaginal tape which has cure rate similar to burch colposuspension ie 85% and simpler procedure .Periurethal bulking agents can be offered which have lesser complications and lower success rates of just 45%. i will offer Anterior colporraphy in case there is associated prolapse though has lower cure rate(66%).Trans obturator tape is a recent technique and cure rates are not yet available.
Posted by Sameena M.
women should be referred to specialist after conservative measures like decrease in weight,decrease in caffeine intake and pelvic floor exercises under community physiotherapist for three months has failed to improve symptoms.if any reg flag symptoms are present refer earlier than later.
once patient has failed to improve by conservative methods arrange for urodynamics.once stress incontinence is confirmed various treatment modalities that can be offered are burch colposuspension,laproscopic colposuspension,MCK procedure,TVT,TOT and anterior vaginal wall repair.
burch colposuspension has high success rate of about 90% .
Posted by A A.
PART A
There are certain signs,symptoms and findings on assessment that indicate referral for further investigations.An urgent referral(with in 2wks) is required in women aged 50yrs or above having microscopic haematuria,those having visible haematuria,women of 40yrs or above with recurrent or persisting UTI associated with haematuria and women with suspected malignant mass arising from urinary tract to rule out malignancy and further management.Further indications for referral include women with symptomatic prolapse visible at or near introitus for surgical management.women with palpable bladder on abdominal examination/bimanual pelvic examination after voiding to rule out neurological cause/retention with overflow. women having urodynamic stress incontinence with failed conservative management and failed medical treatment in women with urge incontinence should be referred for urodynamic investigation and counselling for surgery. women with associated fecal incontinence require assessment for anatomical damage/neurological assessment.Women with symptoms of voiding difficulty like hesitancy,poor stream,straining at voiding(for outflow obstruction/neurologic disease),persisting bladder and urethral pain(for interstitial cystitis/bladder stones or tumour)and suspected neurologic disease to rule out spinal cord injuries/multiple sclerosis and other causes should also be reffered.women with benign pelvic mass and suspected urogenital fistulaes require assessment for surgery.women with previous continence surgery,previous pelvic cancer surgery and previous pelvic radiation surgery require specialist assessment and further management.
PART B
Conservative management in the form of supervised pelvic floor exercises (PFE) for at least three months is the first line treatment option. It is easy, cost effective with no side effects and associated with 27 to 67% success rate. It requires motivation and recurrence rate is high after stopping the treatment. Other therapies like Biofeedback, electrical stimulation and vaginal cones are not associated with improved outcome when compared with PFE alone. But in women who are unable to contract her pelvic floor muscle,bio feedback and electrical stimulation is recommended to aid motivation and adherence to therapy. Vaginal cones and intra urethral devices can only be offered for short period of time and specific purpose like during physical exercise,social functions because of their side effects. Duloxetin which is selective serotonin and noradrenaline re uptake inhibitor can only be offered if woman prefer pharmacological agent over surgery or not suitable for surgery with explanation of its adverse affect like headache, constipation and insomnia. In 50% of the women there is improvement of symptoms with 60% to 100% success rate. Estrogen has no role and phenylproponalamine is not offered because of its cardiac side effects. Lifestyle modifications like cessation of smoking, avoiding of constipation, fluid management and weight reduction add on to the effect of PFE.
If conservative management fails, surgery will be offered after urodynamic investigation. The choice of procedure depends upon presence of prolapse, bladder neck mobility , surgical fitness of woman and wishes of woman regarding long term voiding dysfunction / detrusa overactivity and objective success rate. Retropubic mid urethral tape procedures like Tension Free Vaginal Tape (TFVT) with bottom up approach using macropoous type 1 propoylene mesh is associated with 85% to 90% success rate at 5 years. It is day case procedure, short hospital stay, cost effective with reduced morbidity. Side effects include bladders injury in 8%,voiding dysfunction in 4%and long term risk of tape erosion is unknown.Burch Colposuspension is equally effective with 80% to 90%success rate at 1year and 70% at 5 years. Side effects include detrusor overactivity in 17% and in10% voiding dysfunction( with 1% requiring long term intermittent self cathetarisation). Autologus Rectus facial sling operation is comparable to previous two procedure with 80% success rate and with similar side effects. Synthetic sling procedures using top down approach or transobturatuar approach has 80% success rate but long term data is not available. Laproscopic colosuspension has lower success rate because it requires surgical expertise and is not recommended for routine treatment of stress incontinence. Periurethral bulking agents like collagen,silicone has lower success rate with low operative morbidity have a role when other procedures failed.It has short term continence rate of 48% with improvement rate of 76% in short term. Repeat injections are required and efficacy decreases with time. Anterior colporraphy, paravaginal defect repair, Marshal Marchetti Krantz procedure and needle suspensions are not recommended. Artifical Urinary sphincter is a last resort in women with previous failed treatment due to high morbidity associated with it and 17% require further surgery.
Posted by Manoj M.

M
(a)A woman with suspected underlying malignancy from urinary tract should be urgently referred (within 2 weeks).
Woman aged 50 and above with microscopic haematuria or with macroscopic haematuria or with persistant /recurrent UTI with microscopic haematuria may also suggest underlying tumours/urinary tract pathology and needs immediate specialist referral.
If she has a urogenital prolapse she may needs a specialist as she may want a prolapse repair.
If she has associated neurological signs and symtoms she will need a specialist neurological referral.
If she has a palpable bladder on examination after voiding this may suggest significant residual and need for further investigation and need for specialist referral.
Women with bladder pain or uretheral pain should be considered for referral as may be due to bladder pathology like interstitial cystitis.
If bladder symptoms associated with faecal incontinence may suggest generalised muscular problems and need for specialist referral.
If suspected voiding dysfunction like poor stream may need to exclude urinary tract/bladder pathology and needs for specialist referral.
Any suspected urinary genital fistula need uro-surgical referral for diagnosis and treatment.
Any previous surgeries for urinary incontinence/ pelvic floor surgeries and previous pelvic cancer surgery (or) pelvic irradiation needs specialist input.
Any suspected benign pelvic mass will also need specilaist referral to exclude underlying cause.
Patients quality of life affected and/ non responsiveness of initial management will need specialist input for further investigations and treatment.

(b)
First line treatment option is supervised pelvic floor muscle training(PFMT) lasting atleast for 3 months and atleast 8 contraction 3 times a day.
Before commencing PFMT, pelvic muscle contractions should be assessed digitally to ascertain feasibility of PFMT.
Electrical stimulation and biofeedback is not recommended with PMFT unless the woman cannot actively contract the pelvic muscles.
PMFT has a very good sucess outcome with minimal intervention and no surgery and patient ownership of treatment, lack of motivation and non compliance of treatment may lead to failure of treatment.
Surgical treatment option include tension free vaginal(TVT) tape \'bottom-up\' using macroporous(type1) polypropelyene mesh which has a sucess of 85-90% continence rate over 5 years.
Open colposuspension is an alternative with similar sucess rates to tension free tapes and more long term data available.
Retropububic \'top-down\' like transobturator tape may be used with explanation to patient as long term data not available but short term sucess similar to TVT.
Laparoscopic colposuspension is not recommended and periurethral bulking may need repeated treatment and efficacy diminishes with time and may not be suitable for young woman.
Duloxetine is not recommended as first line treatment but may be used as second line as an alternative to surgery in patient who do not prefer surgery or not suitable for surgery with side effect profile like nausea, headache and insomnia.
Other procedures like anterior colporraphy, paravaginal defect repair, needle suspensiona and Marshall-Marchetti Krantz procedures are not recommended.
An artificial urethral sphincter is only recommended if previous surgeries have failed and need long term followups.
Posted by SUNDAY A.
Sunday\'s answers

a) Women with urinary incontinence should be referred for hospital specialist intervention when they have tried conservative measures and failed- such include change of lifestyle int erms of reducing or cutting down tea and caffeine, appropriate exercise/ pysiotherapy, weight loss and appropriate intake of fluids. They should have been screened and treated for UTI as well. Secondly a failed medical management by the GP would warant such referral and in such situation when the GP is unsure of the diagnosis or in the presence of other urinary symptoms such as heamaturia particularly in the elderly patients or major urogenital prolapse contributing to the symptoms
Previously failed surgical management of urinary incontinence would also warant a referrel to secondary care and those with previous history of urogenital or renal pathologies e.g urethral diverticulum or those with medical problems such as diabetes due to fact that such underlying medical or surgical problem may be contributing significantly to their symptoms. At times some patients demands immediate referral from their GPs to secondary care- such patients should be educated on the neeed to have their symptoms managed in the first instance in the community but their choice should berespected if they are adamant.

b) Treatment options for stress incontinence include; Surgical ,medical ( some instances). The surgical method include;
1.Burch colposuspension which can be done either by laparoscopy or open method with similar success rate about 80-90% and continence rate of about 65-70% 5 years after.
2.Transvaginal tape(TVT) which is now considered as the gold standard with similar success rate of 80-90% and 65-70% continence rate after 5 years compared with Burch colposuspension. The procedure take less time to do and can even been done under local anaesthesia.
3.Transobturator tape (TOT)- slightly lesser success rate compared with TVT.
4.local injection of the bladder neck with bulk agents has been tried with limited success.

In patients who are obese, medical unfit or declined surgery Duloxetine table can be tried but with limited sucess rate but further trial awaited.
Posted by Dr Saritha M.
a)
urinary incontinence severly affects the quality of life. Initial detailed assessment of the type of incontinence and precipitating and predisposing factors are enquired. Impact on quality of life is assessed by using generic and disease specific quality of life questionnaire to assess urinary tract abnormalities and medical conditions accurately and to evaluate the therapeutic efficacy. Previous history of incontinence and surgery for it is an indication for referral. Previous history of pelvic cancer surgery, pelvic irradiation requires specialist referral.
Obstretical history of difficult or operative vaginal deliveries is enquired. Menstrual history of menorrhagia due to fibroid a benign pelvic mass is an indication for specialist referral.On bimanual examination palpable bladder after voiding indicates a need for referral.pelvic floor assessment should be carried routinely. Urine analysis for blood, protein, glucose, leucocytes and nitrites is done. if leucocytes and nitrites are present culture and sensitivity is done. presence of microscopic hematuria in woman aged 50 yrs, visible hematuria, recurrent and persistent urinary tract infection with hematuria in women aged 40 yrs, suspected malignancy needs urgent referral.Other conditions which requires specialist referral are suspected fistula, associated with fecal incontinence or persistent bladder and urethral pain.
b)
Treatment of precipitating factors, weight reduction will be useful in about 50% of woman. Conservative treatment involves pelvic floor muscle training with a hospital phsiotherapist is the first line of treatment for atleast three months with 65-75% success rate. Indicated in breast feeding women, less than six months of post partum, prior to surgical treatment. Medical treatment with Duolxetine has significant improvement used as alternative to surgery after counselling about the adverse effects. Surgical treatment : benefits and risk are explained, Pre operative urodynamic investigation is carried out if there is previous failed surgery, mixed incontinence, neurological disease is suspected.
Burch colposuspension :replacement of proximal urethra into abdominal cavity by suspending para vaginal tissue to ipsilateral ileopectineal ligament.cure rate of 90% at 1 yr, 70% at 5 and 10
yrs.complications include voiding difficulties, detrusor overactivity and enterocoele formation. Mid urethral tape procedure TVT increases urethral pressure, a bottom up procedure using macroporous poypropelene mesh tape. it has got cure rate of 85% at 5 yr with no long term complication. Used in women with previous colposuspension. Convention sling procedure is used in women with narrow vagina, Intrinsic sphincter deficiency with success rate similar to colpo suspension. Anterior colporraphy with badder neck buttress suture is done in women with prolapse where pubocervical fascial defects are corrected. long term outcome is poor, 5yr cure rate is 40%. Peri urethral injection with glutaraldehyde cross linked collagen ,short term benefit is 75% but needs repeated injection,used in elderly frail, unsuitable for surgery. Artificial sphincter in women with intrinsic sphincter deficiency has got 100% cure rate but high complication, needs life long follow up. Marshall Marchetti Kruntz procedure has high cure rate Of 90% but complication of osteitis pubis has decreased the popularity. Laparoscopic colposuspension has showed no signficant difference in outcome than open colposuspension. other procedures like needle suspension procedures, mechanical devices
do not have good evidence.
Posted by Ron C.
RnRn

A.
After ruling out underlying causes such as recurrent urinary tract infections, first line treatment of incontinence are simple interventions. In urge incontinence women are advised to avoid bladder irritants like caffeinated drinks, alcohol and smoking. Voiding diaries are used to alter habits of fluid-intake. This can improve symptoms dramatically, even though response after 3 years may be 40% only. In stress incontinence women are advised to reduce weight if obese, alter diet to avoid constipation and avoid smoking. Combined with physiotherapy for pelvic floor exercises this can improve symptoms in 60% of women. Only those not responding to simple interventions should be referred to the hospital. Suspicion of sinister underlying cause (pelvic mass, haematuria) should be referred straight away. Likewise those with significant prolapse as underlying cause, as response to conservative management is expected less good. Those who have a presentation of mixed or complicated incontinence complaints will also benefit from specialist referral, to determine best approach.

B.
Initial treatment are life-style changes with pelvic floor exercise. Women with prolapse whose symptoms respond well to a pessary, who are keen to avoid further intervention, may wish to continue this. Medical management with duloxetine 20 mg bd is hampered by side-effects (nausea, constipation, visual blurring) and not 1st or 2nd choice. Most other treatments involve surgery, and exact success rates are not entirely clear due to techniques varying amongst surgeons. Suspension procedures (Marshall-Krantz, Burch – requiring abdominal approach) and TVT all have similar rates of success (89% 1 year, 82% 5 years), new-onset urge problems (8-12%) and voiding problems (8-10%). Results and risks for Trans-obturator tape (TOT) seem to be similar to TVT. Anterior repair is less invasive but though short term success may be good, it is <40% after 5 years. Most other procedures have more or less good short term success rates with poor long term response, but have as advantage their relative simplicity, making it attractive in women who are less fit for surgery. Amongst these are peri-urethral bulking agents (expensive; silicone or collagen) and needle suspension with stamey needles. Use of diversion procedures, neo-bladders or artificial sphincters is highly specific. Artificial sphincters have good success rates, but these are compromised by many complications like erosion & infection requiring further intervention in up to 50% of women. Permanent catheterization is most suitable for those who are poor surgical candidates. Silicone catheters, preferably suprapubic, must be used and may be troubled by recurrent/chronic infection and blockage/leaking.
Posted by GHADA AHMAD  M.
Part A
Women should be offered hospital referral for further investigatioons to differentiate between detrusor overactivity and urinary stress incontinence. I she did not improve upon medical treatment or history regard type of incontinence is inconclusive. mid-stream urine analysis to be to rule out infection. Pelvic US scan to be done to exclude a pelviabdominal mass and to measure bladder wall thickness that my suggest interstial cystitis. urodynamic studies ( cystometry) is the gold standard diagnostic tool for type of incontinence. Urine peak flowmetry for bladder neck obstruction, normal >15 ml / sec with total volume 200 ml in 20 sec. Video- cystourothrogram is useful and diagnosis and educational purposes.

Part B
As she was diagnosed as urinary stress incontinence, the traetment options will depend on the severity of disease and its effect on the quality of life as well as the patient\'s wishes.
Nonmedical treatment for mild to moderate cases include bladder drilling and biofeed back via pelvic exercises, vaginal cones, and Kegel perineometry. Success rate 70 % but decreased markedly after stopping exercise.
Duloxitine which is a serotonin-noradrenalin reuptake inhibitor (SNRI) as medical treatment Option is offered but success rate is low.
Sugical options ar variable and depend up facilities and available expertise. Burch\'s colposuspension a well estblished technique with success rate 85 -90 % after one year and 70% after 5 years.
Tension-free vaginal tape ( mid-urethral support) hase the same success rate like Burch an less invasive. TOT is a sling operation but the long-term success rate not established. Laproscopic colposuspension is another technique but needs facilities and skillful laproscopist to be evaluated.
There other tenchniques for failed operations like perurethral bulking agent injectable and bladder neck sphincter.
Other surgical techniques that abandoned like Marshal-Marchetti- Krantz (osteitis pubis) and Kelly plication ( high failure rate)
Posted by Mohamed A.
a)
Women should be referred for hospital specialist intervention after proper clinical assessment based upon proper and accurate history taking, examination and investigations. History taking is very important and should include:

Urine history taking to determine the nature of incontinence whether it is stress, urge or mixed incontinence.

Medical conditions that may exacerbate or co-exist with UI, neurological disorders, diabetes, respiratory, cardiac or renal disorders. medications that may be associated with UI for example sedatives, and smooth muscle relaxants. A drug history should consider previous medication for UI symptoms

Obstetric history should include the number and type of deliveries, the woman’s desire for further childbearing, menstrual history and menopausal status should be determined

Surgical history, Previous surgery for UI or for pelvic organ prolapse may complicate treatment and make diagnosis more difficult

Assessment of the social and functional impact of UI, desire for treatment and expectations


Clinical exam is required to assess fitness for surgery, mobility and dexterity, exclude abdomino pelvic masses and palpable bladder, inspect external genitalia for dermatitis due to chronic exposure to urine, demonstrate SI. Speculum examination for prolapse. Bimanual examination to detect pelvic masses


Initial investigations should include completion of a voiding diary, urinalysis to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine, estimation of post void residual volume by bladder scan or catheterization, Urodynamic studies are indicated when there are multiple symptoms, voiding disorder, before surgical managaement and after previous failed incontinence surgery. Cystourethroscopy and dye test if fistula is suspected


There is a wide range of indications for referral as failed conservative or medical treatment, microscopic haematuria, visible haematuria, recurrent or persisting UTI and suspected malignancy of the urinary tract.
Also, symptomatic prolapse, persisting bladder or urethral pain, clinically pelvic masses or palpable bladder after voiding, associated faecal incontinence suspected neurological disease, symptoms of voiding difficulty, suspected urogenital fistulae and failed previous continence surgery, previous pelvic cancer surgery, previous pelvic radiation therapy.


b)
Treatment options that might be offered to a woman with SI include non surgical measures as weight reduction pelvic floor muscle exercises which should be undertaken for 15-20 weeks, physiotherapy is particularly useful in women unsuitable for surgery or reluctant to do surgery, women who did not complete their family, can also be used postpartum and in women with mild stress incontinence. 27-67% of women may improve. However high relapse when discontinued. Other options include biofeedback, electrical stimulation and vaginal cones.

Treatment of predisposing or exacerbating medical conditions such as diabetes, chronic cough or chronic constipation.

Duloxetine a combined serotonin and noradrenaline reuptake inhibitor can be used with dose of 40 mg twice daily result in marked reduction in incontinence per week and significant reduction in social embarrassment.

Mechanical devices as bladder neck support prothesis , continence guards, urethral plugs and meatal devices are not recommended for routine treatment of SI however can be used occasionally for example during physical exersise.


There are a variety of surgical operations used for the treatment of SI, the choice of which depends on whether it is primary or repeated surgery, mobility of bladder neck, maximum urethral closure pressure and the surgeon experience.

Retropubic procedures as Burch colposuspension aiming to replace proximal urethra within abdominal cavity has a continence rate of 85-90% at 1 year and 70 % at 5 years, lower rates if previous incontinence surgery and may fail if low urethral pressure. Complications include de novo detrusor overactivity 17% and voiding dysfunction 10%, eneterocele and rectocele 14%. Marshal-Markchetti Krantz procedure can be complicated by ostitis pubis (2.5%)

Laparoscopic colposuspension has the advantage of a shorter inpatient stay and rapid return to normal activities, however needs experience and associated with the risks of laparoscopy e.g. bowel injury and 1-10% rate of urinary tract injury.

Sling procedures such as the TVT using prolene mesh at the site of mid-urethra are suitable in cases with low urethral pressure and aim to increase urethral pressure. Suitable for women after colposuspension. Has a success rate of 85-90% at 5 years, however also may fail after previous incontinence surgery. Complications include 8% risk of bladder injury, de novo DO in about 10% and intraoperative bleeding.
Trans-obturator tape can be used with the advantage of avoiding the retropubic space thus minimizing risk of bladder injury, however long term data are not available.


Anterior colporrhaphy aimiming to correct defects in the pubovesical fascia and placement of retropubic sutures (bladder neck buttress) to support bladder neck has a poor continence rates of 66% at 1 year and 37% at 5 years and associated with higher re-operation rates compared to retropubic procedures.

Other surgical procedures include peri-urethral injection of collagen or macroplastique under local anesthesia, don’t have a high success rates, often reserved for patients who are elderly, frail or after multiple failed continence procedures. Often need to be repeated






Posted by Akanksha G.
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].
a)Hospital specialist intervention is necessary when urinary incontinence(UI) is associated with microscopic (women > 50yr) or macroscopic hematuria to rule out genital tract malignancy. women with persistant or recurrent urinary tract infection or UI nonresponsive to conservative management require specialist intervention. UI associsted with genital tract prolapse or significant residual urine assessed clinically does not respond to conservative management and hence require referral to specialist. cases with past history of extensive pelvic surgery, pelvic radiotherapy, or continence surgery should be managed by specialist. suspision of pelvic mass or in the presence of neurological features referral is indicated

b)expectant management with reassurance in a women with out significant UI and allying her fears of any major illness will suffice in some patients. Life style modifications like cessation of alcohol, smoking, moderation/cessation of caffiene, weight loss improve the symtoms in some women. treatment of precipitating factors like constipation, respiratory illness, urinary tract infection is all that is reqiured in a proportion of patients. pelvic floor exercises if performed correctly and routinely is useful in approximately 40% of patients. biofeedback has not shown to improve the outcome.
medical treatment of UI involves use of duloxitine ( 5HT and noradrenaline reuptake inhibitor) it is given in a dose of 40mg twice daily. inital trials have promising results however robust evidence is not available for its longetrm use. surgical tratment is the main stay when conservative management fails. primary surgery carries the maximum chance of success, hence choice of surgery should be carefully made. Burch colposuspension (attaching the paravescical and paraurethral fascia to the iliopectineal ligament ) has a success rate of 85-90% (iimediately) and 70% at 5 yrs. complications with this procedure include, voiding difficulties(10%), prolapse(enterocele/rectocele)17%, denovo detrusor overactivity 15%. the marshall-marchetti krantz operation (suspension of the paravescical and para urethral fascia to the periostium of the pubic bone) is rarely done inspite of a success rate of 85% because of a 2.5% chance of osteitis pubis, also the success at 5 yrs is lower than the burch procedure. laparoscopic colposuspension similar to burch has also been tried with similar/ slightly lower success(75-80%) than burch procedure. the advantages of this are less bleeding, rapid recovery, shorter hospital stay. disadvantages, long learning curve, long operating time, success less than burch procedure.
anterior repair or paravaginal repair no longer reccommended for stress UI since the success rate is upto50-60%. sling operation with autologous, heterologous materials no longer reccomended expect for tension free vaginal tape(TFT) it is a porous prolone mesh inserted at the level of of miduretra. the success rates are upto 90%, these sling procedures carry the risk of erosion and migration of the sling over a period of time. TFT may be recommended for patients with failure of continence surgery. needle procedures have a success rate of upto 85-90% but are no longer recommended because of the risk of erosion and migration. periuretral injections of collagen gives a succes rate of upto50% but a high failure rate by 5 yrs, hence not recommended. other procedures like artificial sphincter insertion involves elaborate surgery with success in upto80% of women but carries significant morbidity and reoperation rate of 17%.
Posted by Prem S.
a) Urgent referral is indicated if microscopic haematuria in above 50 years of age, visible haematuria, recurrent UTIs with microscopic haematuria in 40 years of age or above, suspected mass from urinary tract. In all these its crucial to rule out renal tract malignancy. Symptomatic prolapse and palpable bladder after voiding needs hospital referral as further investigations and surgery may be indicated.
Hospital referral should be considered in previous continence surgery, previous cancer surgery, previous radiation surgery as they can be associated with urogental fistula. Suspected benign abdominal or pelvic mass needs further investigation and surgery. Faecal incontinence, neurological disease might need referral to specialist for multidisciplicary care.
Bladder pain or urethral pain may need Cystourethroscopy to rule out interstitial cystitis and urethral divertiulum respectively.

b) Treatment options for Stress incontinence are life style modifications, surgery and/or medical. Life style modifications include to reduce BMI if more than 30 by regular exercise and diet control. Dietician referral may be beneficial. Regulate fluid intake of 1.5 to 2 litres per day. Supervised pelvic floor exercise for atleast 3 months and it needs physiotherapy referral. Treat associated symptoms like cough, constipation. Advise to stop smoking as it has adverse effect on bladder and urethral sphincter.
Surgery is the mainstay of treatment. Burch Colposuspension and Tension free vaginal tape (TVT) has similar efficacy. Choice is dependant on patient selection criteria and operator expertise. Burch colposuspension has 85-90% continence rate at 1 year and falls to 70% at 5 years. TVT has continence rate of 80%, improvement rate of 90% and efficacy falls over the time. Other suprapubic procedures like Marshall krantz procedure, paravaginal repair and laparoscopic colposuspension\'s efficacy is unclear. Anterior colporrhaphy is less succesful if done as an operation for incontinence. It is ideal for prolapse without incontinence. Periurethral bulking injectable agents are considered if all other therapies are failed. Its efficacy is only short term therefore needs repeated injections. Artificial sphincter is considered in intractable incontinence where all other treatments are failed. It has high morbidity and repeat surgery rate of 17%. Urinary diversion and incontinence pads are other options in refractory cases.
Medical treatment with duloxetine should not be considered as first line due to it side effects. It should not be routinely used as second line. It is considered if the patient is not fit for surgery or declines surgery after proper counselling about its side effects. Estrogen replcement in postmenopausal women improves subjective measures of urinary incontinence but not objective measures.

Posted by SANCHU R.
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].
A) Urinary incontinence has a very high incidence and often can be managed in the community by conservative management.

The patients need to be referred if the symptoms do not respond to conservative management.

Incontinence due to fistula which manifests as continuous leaking of urine needs immediate referral.

Urge Incontinence with hematuria needs urgent referral since it can be a feature of malignancy of the bladder or a calculus in the urinary tract.

Stress incontinence not responding to weight reduction, pelvic floor exercises should be referred. In a patient who has not completed her family or does not want surgery or high risk for surgery, Duloxetine can be tried and referred if all these conservative measures fail.

Urge Incontinence can be managed with Bladder Drill and medically with Anticholinergics namely Oxybutynin, Tolterodine, Solfenacin etc and referred if the patient does not respond.

Patients with Mixed incontinence will have to be referred for Urodynamics and specialist input.

Incontinence due to nerological problems should be referred.

B) The initial management would be changing their lifestyle with weight reduction, reduction in caffeine and alcohol intake.

Pelvic floor exercises should be offered. 60% respond to pelvic floor exercices.

In a patient who has not completed her family,not willing for surgery or high risk for surgery, Duloxetine is started with a success rate of about 50%

In those in whom conservative methods have failed, retropubic sling procedure -The Tension-free vaginal tape is offered with a 80-90% success rate.
The Burch colposuspension has a similar success rate, the long term results are known, but needs an abdominal incision, can be done laparoscopically.
The Transobturator Tape has a higher complication rate and a lower success rate than these procedures according to latest data.
The peri-urethral injections have a lower success rate of about 60%
and the efficacy diminishes with time.
The MMK procedure is not recommended due to high rate of complications.


Posted by PAUL A.
A/
Failed medical treatment is an indication for specialist refeeral (1) . Treatment can fail because of wrong diagnosis. Woman may have detrusor overactivity, stres or mixed incontinence. The symptoms may overlap. Therefore, where GP is not sure of diagnosis, it is appropriate to refer the woman for investigation and appropriate treatment.
Incontinence may be as a complication of medical or surgical treatment. Incontinence following pelvic surgery like hysterectomy, incontinence surgery or prolapse repair require urgent specialist referral, because it may be due to urinary tract fistula. Also, radiotherapy can cause fistula (1) .
Recurrent infection causing incontinence should be referred for specialist care does recurrent infection cause incontinence? . Women themselves may request for referral (1) to specialist unit, most especially if the symptoms is affecting quality of life and want answers and urgent specialist care. there will be features in history (for instance, bladder pain, fecal incontinence, symptomatic prolapse), examination (mass), investigations (haematuria)…
B/
Treatment can be conservative, medical, use of device or surgery. Conservative treatment would be recommended as initial treatment. I would encourage obessed woman to lose weight, reduce cigarette smoking and reduction in fluid intake. Any provocative factors like chest infection or constipation would be treated. Avoidance of lifting heavy objects. Success rate of this measures is about 40-50% (1) .
Supervised Pelvic floor exercise would be offered to all women with stress incontinence, except the frail and debilitating women who would not be able to perform it. I would offer it for about 6months, and its success is about 50 to 60% (1) .
I would offer medical treatment for those who are unfit or doesn\'t want surgery. Serotonin and Noradrenalin reuptake inihibitor like Duloxetin may be effective (1) .
I would offer Trans Vagina tape[TVT] to women who are fit for surgery. it is a sling procedure with 85% cure rate (1) in 1st year, but becuase it is a new method, long term effect is not know yet. There are risk of bladder perforation, erosion and detrusor overactivity.
Burch colposuspension is another option, with a similar success rate as TVT[85%], with 70% 5years cyre rate (1) . The side effect include De-nove detrusor over activity, bladder injury (1) .
Marshal Markhet Khants is also a retropubic surgery but I would not recommend it you were asked about those you would offer because of risk of oseitis pubis.
Anterior vagina wall has less complications, with less risk of catheterisation, but the success rate is just about 66% in 1st year reducing to about 35% by 5years. Therefore in long term, it is not an effective surgery. It is useful for women with cystocele.
If a woman has had previous surgery that failed I would recommend Bulking agent like collagen or silicone, injected to the paraurethral area. less effective, about 30% you can offer TVT if failed colposuspension… .
Other method include artificial urethra spincter. what about trans-obturator procedures?
Devices like continence pad or urethra plug would be offered to those women with failed previous surgery or unfit for surgery. The success mainly depend on usage as it is not curative. There is increase risk of urinary tract infection.
I would provide written information leaflet, to enable woman make a well informed decision. Proper documentation of management plan.
Posted by PAUL A.
LEEN
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].

(a) Women with stress or mixed (urge and stress) urinary incontinence, are usually advised to lose weight as well as make lifestyle changes (such as reduce caffeine intake) and community physiotherapist can teach them pelvic floor exercises. However, if her symptoms are not improved; or has a significant impact on her quality of life and is getting worse, then hospital assessment should be sought. Women with previous incontinence surgery (1) should also be referred to a urogynaecologist.
Women who also complains of concurrent prolapse (1) should also be referred to hospital, as she may need treatment for it as well as for her incontinence.
Women with urge incontinence, who are not responding or tolerating bladder retraining, or first line pharmacological treatment should be assessed by a urogynaecologist (1) .
It is also important, if the GP suspects that her incontinence might require surgical treatment, such as urinary tract fistula, the patient should be reviewed in hospital.
If you were asked to give a talk to GPs about when to refer, how would you approach it? (a) Features in history – symptomatic prolapse, continuous leaking suggestive of fistula, haematuria, previous incontinence surgery / radiothersapy…(b) features on examination – abdo-pelvic mass, (c) investigations – haematuria (d) initial diagnosis – fistula / neurological disease (e) woman’s wishes..
(b) Lifestyle changes such as weight loss (if obese) and cutting down on caffeine; and together with pelvic floor exercises may help improve stress urinary incontinence in approximately 50% of women (1) .

There are a few different surgical options, and the type of surgery may depend on whether there is marked urethral sphincter weakness, previous history of incontinence surgery or whether the woman has risk factors that increases her general anaesthetic(GA) risk, as well as patients\' choice.

Burch colposuspension(BC) is the gold standard, due to lots of longterm data; and is suitable for women with urethral sphincter weakness. It improved incontinence in 85-90% of women by 1 year (1) , but is associated with a risk of iatrogenic detrusor instability. It also requires the patient to undergo a GA (1) . Marshall Marchetti Kranz procedure has also similar incontinence rate to burch colposuspension, but is not performed as often now, due to an associated adverse risk of osteitis pubis you were asked about those you would offer .

Tape procedures such as Tensionfree vaginal tape(TVT) lifts the midurethra, and is suitable in patients who has previous failed incontinence surgery (such as burch colposuspension). Success rates are comparable to BC, 85-90% (1) , but has a higher bladder injury risk of 8%. It is also associated with a risk of transient detrusor instability and voiding dysfunction (1) . It has the advantage of being done under local or regional anaesthetic (1) making it suitable for patients with a higher GA risk. Trans obturator tape (TOT) (1) and TVT-obturator are newer and seems to have similar success rates to TVT, but require long term data for comparison.

Anterior colporrhaphy has poor success rates for curing incontinence, and majority(70%) of improvement of continence tends to regress within a year. It is associated with a lower morbidity and complication rate compared to the above procedures. would you offer this as treatment for urinary stress incontinence?

Urethral buttress (1) and neo-urethra has success rates of approximately 70%, but tends to require repeat procedures every few years. However, the morbidity associated with these procedures are much lower.

Duloxetine (1) can be used if surgery is not suitable or if the patient refuses surgery. It has lots of side effects, including dry eyes and mouth, and a success rate of approximately 60-70%.
Posted by PAUL A.
A-
Specialist referrals may need in following conditions – 1 DO NOT NUMBER YOUR ANSWER . True incontinence there is no such thing as true incontinence. The term ‘genuine’ stress incontinence is also no longer used following, surgery, radiotherapy, obstetric injuries and other genital tract trauma with true incontinence example straddle injuries ? meaning where there is minimal intervention that community staff can do.2.Failed medical management of Urge incontinence (1) specially with mixed stress incontinence where urodynamic studies and proper diagnosis need for further management. .3 failed conservative management of stress incontinence with poor quality of life scores.4Medical and surgical diseases like what? associated incontinence where failed change of medication and conservative managements ex Spinal cord lesions and Multiple sclerosis (1) .5 Any patients with minimal response to conservative management like weight reduction, pelvic floor exercise, life style modification like cut down caffeinated drinks where patient is not happy that seek specialist services.6 Patient who have symptoms suggestive of urogenital malignancies which symptoms? where urgent and appropriate investigation-ex asymptomatic haematuria (1) 7. Failed or complications following previous incontinence surgical procedures-Ex –Sparc tape erosions

If you were asked to give a talk to GPs about when to refer, how would you approach it? (a) Features in history – symptomatic prolapse, continuous leaking suggestive of fistula, haematuria, previous incontinence surgery / radiothersapy…(b) features on examination – abdo-pelvic mass, (c) investigations – haematuria (d) initial diagnosis – fistula / neurological disease (e) woman’s wishes..
B-
Urinary stress incontinence need to be confirmed by Urodynamic studies as Genuine Urodynamic is the correct terminology stress incontinence(GSI) but conservative management can be undertaken without urodynamic studies. Need to explore and examine for symptoms which may need surgical repair that will relieve Stress incontinence ex complete procedentia
Options available for GSI are -1 Conservative management Iwill advice her that improtence of conservative management lie weight reduction , pelvic floor physiotherapy with dedicated pelvic floor physiotherapist where supervise is essential in most of patient for correct technique where success rate over 50% (1) but need to continue life long , life style modifications like stop smoking, avoid excess drinking of water at night ,management of chronic constipations with change of diet and stool softening agents ,change of medications example like Angiotensing converting enzyme inhibitors where chronic cough present as side effects of medication (1) . Associated medical problems need to be controlled well like Congestive Cardiac failure, Chronic Obstructive Airway disease with recurrent chest infections –may need appropriate medical specialist review. Conservative management is paramount importance for initial management for stress incontinence where over 50%can have cure. I will advice to try conservative management at least 6/12 before surgical procedures.Contineance Sister can educate ongoing care for these patients.
2 .Medical management where pt is waiting for surgery or does not keen on surgery ,SNRI (Serotonin Noradrenalin Reuptake Inhibitor)–Duxoletine (1) is effective drug that stress incontinence can be controlled for short term (12/weeks), 40mg need to date twice a day ,has side effects of and cannot take with other antidepressants like SSRI.
3. Surgical management –Depend on whether pt has any other anterior vaginal wall prolapsed or uro- genital prolapsed . If she has large anterior wall defect pt may have simple surgery like anterior repair with bladder buttressing suture poor success rate and should not be offered .which has 30% cure rate in over 5 years Simple uncomplicated GSI can be nearly cured with TVT-(Trans Vaginal Tension free Tape) procedure where proline –synthetic knitted mesh apply across the middle part of urethra under regional anaesthesia (1) as day procedure and has success rate of 90 after 1 year and 70% over 5 years (1) unfortunately long term data is lacking at this stage .This procedure has complication tape erosions and inherit risk of bladder perforation -10% which can be check immediately or during procedure .As like any incontinence surgery TVT can develop den ova bladder overactivity and voiding difficulty.
I will explained other Surgical procedures to Patient r like–Burch colposuspension (1) gold standard at this sate –where proximal urethra and bladder neck elevation under open or laparoscopic procedure, short term success rate is similar to TVT but long term data is available ,this procedure is preserved for pt who have failed simple procedures like TVT .Burch colposuspention has similar rate of complications like denova detrusor overactivity and voiding difficulties (1) . other surgical procedure which I will discourage her to undergo is MMK- Marshal Markhet Khant procedure which distal urethra anchored to pubic bone(retro pubic ) has rare oseitis pubis complication and alternative procedures have similar success rate with less complications so would you offer her this procedure? .
4. Patient who had multiple surgeries and still incontinent i will explained Para urethral bulking agents (1) where Collagen and other synthetic material –Silicon inject in to proximal para urethral area, success rate is less than 30% may need to repeat the procedure. Other options like urethral plug is not gain wide popularity and have high urinary tract infection risks, artificial sphincter and other experimental procedures currently not freely available. I will explains her all the available options and give her written self explained documents.
Posted by PAUL A.
Patients are referred to hospital for better facilities of investigations and treatment.patients may need urodynamic investigations(UDS) if she had urinary stress incontinence which was being treated in community with pelvic floor excercises but this failed (1) and so will need surgery.According to NICE guidelines UDS needed first to exclude associated detrusor instability or voiding dysfunction. Patients who had detrusor instability and being treated with bladder drill at home without success might benfit of the proceder being done on an in patient basis but it will be more costy.Patients with incontinence associated with hematuria (1) might need admission foe cystoscopy ,but this can be done on day surgery unit.Patients who had associated urinary tract infection with incontinence will need specialist hospital intervention why? UTI can be treated in community .A patient with uncontrolled diabetes associated with urgency incontinence will need hospital admission and intervention to control her diabetes.Patient with painful micturition,urgency incontinence and hematuria long standing will need cystoscopy to exclude interstitial cystitis( glomerulation and Hunner ulcer), or stone. Patient referral for urinary incontinence are low ,this might be due to patient not seeking medical advice or the general practitioner treating her for another reason.Written information ,teaching GPs regarding incontinence and directions to patient to whom she should seek will icrease such referrals.

If you were asked to give a talk to GPs about when to refer, how would you approach it? (a) Features in history – symptomatic prolapse, continuous leaking suggestive of fistula, haematuria, previous incontinence surgery / radiothersapy…(b) features on examination – abdo-pelvic mass, (c) investigations – haematuria (d) initial diagnosis – fistula / neurological disease (e) woman’s wishes..

Conservative measures should be used first.Pelvic floor exercises to increase pelvic muscle tone have success rate of 27-67% (1) ,but when stopped recurrence of symptoms occur.Vaginal cones and pelvic faradism will help to increase muscle tone but studies showed insignificant effect.Mechanical devices can be used but associated with trauma and bleeding.They can be used during acts of exersion eg playing squash.
Medical treatment using Dulexetine should not be used as first or second line treatment which inhibit the reuptake of serotonin and nore epinephrine increasing the uretheral muscle tone, will help in some patients but this limited by its side effects as nausea, dry mouth and anorgasmia.
UDS should be done before embarking on surgical treatment after failure of conservative treatment. The surgical procedure recommended by NICE is the Tension free vaginal tape(TVT) ,being a simple procedure ,can be done under local anesthesia (1) ,even on an out patient measure and gived success rate equal to open Burch colposusspension (80-90% cure rate even after 5 years) (1) .It is associated with less detrusor instability and voiding dysfunction than Burch but there is risk of bladder perforation 8% and tape erosion.Another sling procedure like TVT but still studies being gathered about it is the Transobturator tension free tape (1) is associated with less bladder injury than the TVT but more risk of erosion.
Laparoscopic coposuspension give less success rate than open Burch and will need more expertise what about open colposuspension? You have only mentioned this to say success rate of TVT is similar
Suburetheral implants ? implants of what? are easy to do with low complications rate but also low success rate. Other operations that were used for stress incontinence but failed to continue in its treatment due complications or low cure rate include ,Marshal Marchette operation and anterior vaginal wall repair with Kelly,s suture would you offer these?
Posted by PAUL A.
(A) Majority of the women with urinary incontinence are managed at primary health care centre , after taking detailed history, to determine the possible causes of incontinence, examination of the women to rule out uterovaginal prolapse and pelvic masses and investigations like MSU to rule out UTIs , frequency volume charts to determine intake and out put record and urinary diary over a week for frequency and volume of urine voided. There are clear referral pathways at primary care and the following women should be referred for specialist management this is what you were asked about, so why have you wasted time above?? .
Stess incontinence associated with UTIs wich are resistant to oral antibiotics, recurrent UTIs or associated hematuria (1) should be referred.
Incontinence associated with voiding dysfunction (1) , uterovaginal prolapse , pelvic masses (1) and genital tract malignancy also needs referral.
Women with mixed incontinence like frequency, urgency , urge incontinence, nocturia ( after excluding diabetes and diuretics intake) should be also be referred.
Failed treatment at GP level wheather life style modification , pelvic floor exercises and medical treatment should be referred for further investigation (1) .
Previous failed incontinent surgery (1) should immediately be referred.
If woman wishes to be seen by a specialist (1) .
Incontinence could be due to fistula (1) with symtoms of continous leaking confirmed by three swab test is referred for evaluation to rule out bladder carcinoma or due to radiation for cervical carcinoma.
you will earn marks if you had a systematic approach – features in history, examination, investigations, initial diagnosis and woman’s wishes
(B) Treatment options depend on the age of the women why?? , other types of incontinence , voiding dysfunction previous failed conservative and medical treatment at primary care , previous failed surgical treatment, health of the women and co morbidities, associated uterovaginal prolapse and avaiability of experties.
I will review her referral file for relevent points from the history, examination , investigations not answering the question – which treatment options would you offer? and treatment offered at GP level . I will discuss her sympoms , if it suggests stress incontinence ??? the question says she has urinary stress incontinence , I will offer a pelvic examination to confirm it objectively and also to rule out prolapse, pel;vic masse . I will examine TREATMENT OPTIONS!!! tone of the pelvic floor muscles , the perineal sensations and mobility of urethra .The treatment options for stress incontinence are life style modification like decreasing cofee, tea, alcohol, change of clothes (1) , change in timings of diuretics if she is on and treatment of diabetes , chest infection and constipation. Pelvic floor exercise (1) for 15-20 weeks improves the quality of life by decreasing incontinence in 27-67% of women .simple , non invasive and cheap but needs motivation and referral to physiotherapist.These treatments are provided if not recieved at primary level.
Medical treatment for stress incontinence includes SNRI Duloxetine 40 mg twicw daily for 12 weeks NOT FIRST / SECOND LINE TREATMENT and alpha adrenergic agonist phenyle propanolamine.both increases sphincter muscle tone in about 80% at one year but efficacy decreases after stoppping .

Before considering surgical treatment urodynanic studies are offered to confirm urodynamic stress incontinence.
Surgical options include colposuspention procedures. The aim is to elevate proximal urethra in to thw abdomen .these are Burch colposuspention when the para urethral tissue is elevated to ipsilateral ileopectineal ligament. Can be performed via laparotomy or laparoscopy. Cure rate at one year is 85-90% and 70% at five years laparoscopic procedures have lower success and should not be offered.It can cure mild cystocele but causes denovo detrrusor overactivity in 17%, voiding dysfuntion in 10% and concomitant enterocele in 14% (1) .
MMK procedure is not recommended due to 2-3 % risk of osteitis pubis SO WHY ARE YOU OFFERING / DISCUSSING IT?? .

Sling procedures includes TVT and TOT .Mersiline taps are applied at mid urethra under local or regional anesthesia. Useful in stress incontinence due to intrinsic muscle weekness.Cure rate at one and five years are similar 85-80% and 80% respectively (1) Do you have 5 year data for TOT?.Risk of denovo detrusor overactivity is 10%, voiding problems is 4% and ureteric injury is 9% (1) .
Suitable for previous failed surgery and very frail women.
Anterior repair may be help full if there is urethral kinking but it may worsen the symptoms by un masking underline occult stress incontinence.
Other options are periurethral bulking agents ? success rate , continent devices, urethral plugs .Rarely neourethra formation , artificial sphinter or urinary diversion may be needed
I will provide her with informations about support groups like British INCONTINENT SOCIETY.
Posted by PAUL A.
a)Microscopic hematuria in a lady more than 50 years and persistent and recurrent UTI in more than 40 years as also any visible hematuria (1) should be seen by a specialist to rule out any malignancy. a suspected pelvic mass (1) arising from the pelvis as also symptomatic prolapse eaching at or below the introitus (1) needs hospital referral as causative pathology has to be treated.A palpable bladder after voiding on pelvic examination could suggest a bladder mass and needs specialist intervention.Also other conditions like persisting bladder and uretheral pain (1) ,associated fecal incontinence (1) you need a discussion rather than just saying this needs referral and that also needs referral,suspected neurological disease needs hospital referral for multidisciplinary care.Any suspicion of a urogenital fistulae how will this suspicion arise? ,previous incontinence repair,previos cancer surgery or pelvic irradiation (1) also need Consultant evaluation in hospital.Any voiding difficulty needs detailed evaluation and thus hospital referral. need systematic approach – features in history, examination, investigations, initial diagnosis; woman’s wishes
b)It is important to classify type of incontinence at the outset for clear management.Stress incontinence needs life-style modifications like weight reduction if BMI>30 as that would reduce the intraabdominal pressure causing incontinence.Also any excessive intake of caffenine and alcohol should be reduced as also the fluid intake ? success rate .Supervised pelvic floor muscle training programme has been proven to be successful if correctly done 8 times three times a day for 3 months you were explicitely asked about success rates .If symptoms are not controlled by conservative measures then surgical procedures like retropubic mid-uretheral tape suspension using macroporous polypropylene meshes which have been proven to be 85% effective at 1 year (1) can be offered.It has the advantage of being a day-case procedure (1) with minimal morbidity.Drugs like duoloxetine should not be used as first line therapy and should onlu be used as an adjunct to surgery NO – NOT RECOMMENDED TO BE USED IN ADDITION TO SURGERY .Also Bursch colposuspension though a major surgery with more morbidity has success rates of 85% cure rate at 1 year (1) post-procedure.Surgeries like Marshall-Marchetti-Krantz procedure are associated with oeteitis pubis and thus uncommon NOT RECOMMENDED .Peri-uretheral bulking agents need repeated injections as there effect dcreases over time and thus only preferred for women in whom major surgery is to be avoided (1) ? SUCCESS RATE . In a lady with urge or mixed incontinence question says urinary stress incontinence – how can she have urge or mixed incontinence?? life style modifications go alongwith bladder retraining for 6 weeks.the lady is advised to postpone voiding to only fixed intervals and gradually increase the interval between voiding episodes tby 15 minutes.this has been found to be very successful.Also is symptoms are not improved by conservative measures then drugs like immediated release oxybutynin are found to be very effective in treatment.Side-effects like dry mouth,constipation are known and patient has to be counselled about continuing treatment.Also drugs like darefenacin,solefenacin,trospium can be used and have been found to be equally efficacious with less side-effects as they are selective for the m3 receptor.Sacral nerve stimulation can be offered to women who do not respond to medical management based on their response to percutaneous nerve stimulation results.this has been found to be very effective as other surgeries are very expensive.
Posted by PAUL A.
Symptomatic categorisation of the urinary incontinence based on the reports from the patient and history taking is sufficient to initiate a noninvasive treatment option at the primary health care level.Urinary incontinence is not life threatening but can be quite distressful for the patient,if the patient requests (1) and is keen for the specialist referral her wishes must be respected.Indications for hospital referral can be divided into urgent and not urgent.Under the urgent referral category patients with microscopic haematuria and aged above 50,any recent or persisting UTI with haematuria (1) aged 40 and above and any suspected malignant mass (1) arising from the urinarytract.The above mentioned conditions with any form incontinence requires urgent referral to the hospital for specialist intervention.The other indications for specialist referral are any persisting bladder or urethral pain (1) , associated faecal incontinence,suspected neurological disease,urogenital fistulas this is a list, not a discussion .If the patient has undergone any pelvic cancer surgeries,continence surgeries,radiation therapy also need the referral (1) .Any incontinence associated palpable bladder on bimanual or abdominal examination after voiding should be referred to a specialist.Patients who did not respond to medical or pelvic floor exercises also require referral (1) .


The treatment options can be conservative,medical and surgical.After assessing symptoms,associated factors like prolapse,medical conditions,previous continence surgeries,mobility of the bladder,surgeon expertise , fitness for the sugery the treatment should be initiated.Would start with the conservative treatment unless any contraindication,treat the underlying conditions if any like chronic cough,constipation,life style modifications like quitting smoking .50% (1) of women actually benefit and may evade sugery.Pelvic floor exerceises are effective,27%-67% (1) women benefit .It has to be done under physiotherapist supervision for 15-20 months.It needs motivation and will inform the patient about the recurrence after stopping the exercises.Mechanical devices bladder neck support prosthesis are an option if she has incontinence only during specific activites,success rates upto 87% have been noted after 12month usage.
Medical options like SSRI duloxetine (1) 40mg twice daily can be used for short term while awaiting for surgery.It is associated with significant reduction of incontinence and also psychological impact with improvement in quality of life.Inform her that it cannot be used as first line treatment.Explain to her tthat side effects are significant like headache,nausea,decreased libido,dry mouth,and the drug cannot be stopped abruptly due to withdrawal effects.It has to be weaned over 2 weeks
Every patient contemplating surgery should be offered physiotherapy unless contraindicated.Surgery has to be preceded by urodynamic studies.Retropubic surgeries like Burch colposuspension is the gold standard surgery with 85%-90% continence rates by 1 year (1) and 70% by 5 years.Complications are 10% voiding dysfunction,10% denovo detrusor instability,5-17% enterocele and rectocele formation (1) .Sling operations like TVT are as effective as colposuspensions with 85 -90% at 5 years (1) .the complications are bladder injury 8%.Anterior repairs are associated with high failure rates 27% compared to retropubic and sling procedures and hence routinely not done would you offer this in a woman with urinary stress incontinence? .Other supra pubic procedures like Marshall Marchetti Krantz procedure is not performed due to high failure rates and complications like osteitis pubis in 2.5% patients so you would not offer this .Laparoscopic colposuspension is not routinely offered because requires highly skilled surgeon as it is associated with complications .
Would inform her other procedures like periurethral bulking agents,neo urethra,artficial sphicters have a role if other procedures fail.They have short term continence rate about 48% (1) and require repeat surgeries.
Would give the patient written information , and would take her wish into consideration before initiating treatment.Inform her about the support groups like British Incontinence Society for further support

Good answer – would have earned more marks if you had included more discussion in (a) [you have used half as much space as for (b) yet same marks are allocated] and you should have focused on procedures that you would offer in (b)
Posted by PAUL A.
a)Urinary incontinence can be distressing problem and generally requires specialist care both for urodynamic studies and treatment. An urgent referral is required if symptoms are of constant dribbling (1) i.e urinary tract fistula.,previous history of pelvic surgery,any previous surgery for incontinence (1) ,any history of treatment of pelvic malignancy especially radiation therapy,if the patient has associated rectal incontinence also.If there is associated prolapse,any pelvic mass ,palpable bladder after voiding.a urine routine examination shows hematuria (1) (painless)especially if the patient is above 40.If the symptoms do not improve after 3 months of pelvic floor exercises the patient needs referral to a specialist (1) You have simply written a list with no discussion – you have one side of A4. All you needed to do was add some context to this list and you would have doubled your marks. For instance, pelvic mass or haematuria in an older woman should prompt urgent referral. You also need a systematic approach. In the exam, you might not remember such a list.
b)treatment options which i would offer ,first would be conservative management which includes pelvic floor exercises.this can be especially helpful in postpartum patients ? success rate .Some women are benefited by contigard a vaginal tampoon which gives bladder neck support.A serotonin reuptake inhibitor and noradrelanine reuptake inhibitor duloxetine is available and has good results in urodynamic stress incontinence was tested in women with urinary stress incontinence or urodynamic stress incontinence? Not to be used as first / second line treatment .a dose of 40 mg twice daily gives good results ? success rate – what does good results mean? .If there is failure of conservative management surgery should be offered of burch colposuspension gives the best results(85% cure rates (1) ).Laparoscopic colposuspension can also be done but increased chances of bladder injury lower success rates and should not be offered .i would offer TVT that is transvaginal tape which has cure rate similar to burch colposuspension ie 85% is this at 1 or 5 years? and simpler procedure .Periurethal bulking agents can be offered which have lesser complications and lower success rates of just 45% (1) . i will offer Anterior colporraphy in case there is associated prolapse though has lower cure rate(66%) should not be offered as low success rate .Trans obturator tape is a recent technique and cure rates are not yet available short-term data available .
Posted by PAUL A.
YOU HAVE 20 MARKS AND 2 SIDES OF A4 – You cannot expect this answer to pass women should be referred to specialist after conservative measures like decrease in weight,decrease in caffeine intake and pelvic floor exercises under community physiotherapist for three months has failed to improve symptoms (1) .if any reg flag symptoms what are red flag symptoms? Where do you expect the examiner to give you 10 marks? If this is the sum total of your knowledge, you should do some reading before attempting the question are present refer earlier than later.
once patient has failed to improve by conservative methods arrange for urodynamics.once stress incontinence is confirmed various treatment modalities that can be offered are burch colposuspension,laproscopic colposuspension,MCK procedure,TVT,TOT and anterior vaginal wall repair.
burch colposuspension has high success rate of about 90% (1) the question asked for success rates – why did you quote it for colpo but not for any of the others? Your answer suggests you are not serious about passing the exam .
Posted by PAUL A.
PART A
There are certain signs,symptoms and findings on assessment EXCELLENT approach. To be pedantic, I will say symptoms (because you take a Hx first), signs and findings on investigation (assessment includes Hx, examination and investigations) that indicate referral for further investigations.An urgent referral(with in 2wks) is required in women aged 50yrs or above having microscopic haematuria,those having visible haematuria (1) ,women of 40yrs or above with recurrent or persisting UTI associated with haematuria and women with suspected malignant mass arising from urinary tract to rule out malignancy and further management.Further indications for referral include women with symptomatic prolapse visible at or near introitus (1) for surgical management.women with palpable bladder on abdominal examination/bimanual pelvic examination after voiding (1) to rule out neurological cause/retention with overflow. women having urodynamic stress incontinence with failed conservative management and failed medical treatment in women with urge incontinence should be referred for urodynamic investigation and counselling for surgery (1) . women with associated fecal incontinence (1) require assessment for anatomical damage/neurological assessment.Women with symptoms of voiding difficulty like hesitancy,poor stream,straining at voiding (1) (for outflow obstruction/neurologic disease),persisting bladder and urethral pain (1) (for interstitial cystitis/bladder stones or tumour)and suspected neurologic disease to rule out spinal cord injuries/multiple sclerosis and other causes should also be reffered.women with benign pelvic mass and suspected urogenital fistulaes ? symptoms – continuous dribbling require assessment for surgery.women with previous continence surgery,previous pelvic cancer surgery and previous pelvic radiation surgery require specialist assessment and further management (1) what about the woman’s wishes?.
PART B
Conservative management in the form of supervised pelvic floor exercises (PFE) for at least three months is the first line treatment option. It is easy, cost effective with no side effects and associated with 27 to 67% success rate (1) . It requires motivation and recurrence rate is high after stopping the treatment. Other therapies like Biofeedback, electrical stimulation and vaginal cones are not associated with improved outcome when compared with PFE alone. But in women who are unable to contract her pelvic floor muscle,bio feedback and electrical stimulation is recommended to aid motivation and adherence to therapy. Vaginal cones and intra urethral devices can only be offered for short period of time and specific purpose like during physical exercise,social functions because of their side effects There is only going to be 1 or max 2 marks for PFE as there is lots more to write so you should not spend this much time / space discussing it . Duloxetin (1) which is selective serotonin and noradrenaline re uptake inhibitor can only be offered if woman prefer pharmacological agent over surgery or not suitable for surgery with explanation of its adverse affect like headache, constipation and insomnia. In 50% of the women there is improvement of symptoms with 60% to 100% success rate. Estrogen has no role and phenylproponalamine is not offered because of its cardiac side effects you will not offer it so do not write it. If you get to the end of your answer and still have space / time then throw it in . Lifestyle modifications like cessation of smoking, avoiding of constipation, fluid management and weight reduction add on to the effect of PFE should come before PFE / medical treatment. / SUCCESS RATE .
If conservative management fails, surgery will be offered after urodynamic investigation. The choice of procedure depends upon presence of prolapse, bladder neck mobility , surgical fitness of woman and wishes of woman regarding long term voiding dysfunction / detrusa overactivity and objective success rate. Retropubic mid urethral tape procedures like Tension Free Vaginal Tape (TFVT) with bottom up approach using macropoous type 1 propoylene mesh is associated with 85% to 90% success rate at 5 years (1) . It is day case procedure, short hospital stay, cost effective with reduced morbidity (1) . Side effects include bladders injury in 8%,voiding dysfunction in 4%and long term risk of tape erosion is unknown.Burch Colposuspension is equally effective with 80% to 90%success rate at 1year and 70% at 5 years (1) . Side effects include detrusor overactivity in 17% and in10% voiding dysfunction (1) ( with 1% requiring long term intermittent self cathetarisation). Autologus Rectus facial sling operation is comparable to previous two procedure with 80% success rate and with similar side effects will you offer this operation? . Synthetic sling procedures using top down approach or transobturatuar approach has 80% success rate but long term data is not available (1) . Laproscopic colosuspension has lower success rate because it requires surgical expertise and is not recommended for routine treatment of stress incontinence so you will not offer it . Periurethral bulking agents like collagen,silicone has lower success rate with low operative morbidity have a role when other procedures failed.It has short term continence rate of 48% with improvement rate of 76% in short term (1) . Repeat injections are required and efficacy decreases with time. Anterior colporraphy, paravaginal defect repair, Marshal Marchetti Krantz procedure and needle suspensions are not recommended. Artifical Urinary sphincter is a last resort in women with previous failed treatment due to high morbidity associated with it and 17% require further surgery.

VERY GOOD ANSWER AGAIN.
Posted by Nur Sakina K.
NSK

A)
Referral will depend on findings during history,examination and initial investigation. Urgent referral is needed if frank or microscopic hematuria present. Microscopic hematuria in woman at least 50 years old maybe the first sign of bladder tumour. Presence of recurrent or persistent urinary tract infection (UTI) with hematuria in a woman at least 40 years old must be referred urgently. If a pelvic mass is suspected, arising from the urinary tract, urgent referral is needed.
Referral should also be made for woman presenting with symptomatic prolapse that is visible at or below the introitus. If a palpable bladder is noted post micturition on bimanual palpation or physical examination – she too should be referred for specialist input. This denotes voiding dysfunction with significant post void residual volume.
Referral should be considered in a woman with clinically benign pelvic mass, persistent bladder or urethra pain or incontinence associated with fecal incontinence (soiling). In a woman with previous continence or pelvic cancer surgery, referral is considered as treatment of incontinence may prove difficult in them. This should also be considered if they have had radiotherapy treatment previously. In suspected neurological disease or urogenital fistulae, referral is considered for specialist input. Woman with voiding difficulties should be reviewed by a specialist as further investigation is needed. Referral to hospital for specialist input should always be considered if initial community management or treatment fails.

B)
Treatment begins with pelvic floor exercises for at least three months. She should be referred for physiotherapist input to teach appropriate pelvic floor exercises and induce patient motivation. 50% women note an improvement of their symptom with PFE alone. However, once stopped, symptom can recur. Lifestyle changes such as weight loss in woman with BMI>30 and reducing high fluid intakes to 1.5L/day helps improve symptoms in up to 50% women.
Drug therapy with duloxetine, a Serotonin Noradrenaline Reuptake Inhibitor (SNRI) has been used. However, NICE has recommended it should NOT be used as 1st or 2nd line treatment for SUI. It should be considered as a 2nd line treatment in women who refuse or is unsuitable for surgical intervention. Its main side effect is nausea, which tends to improve over several weeks. It reduces incontinence in up to 50% women and the affects are mainly seen within 1-2 months of use. If no response is seen after this period, it is probably not worthwhile to continue this treatment.
Systemic HRT has no benefit in improving stress incontinence and is not recommended.
Incontinence pessary –such as ring, dish has also been used. It acts by compressing urethra against upper portion of the posterior symphysis pubis. It provides continence in up to 40% woman. However, several studies demonstrate only short-term efficiency (1 month).
Surgical treatment is only considered if conservative measures fail. Options include: tension free vaginal tapes (TVT) and transobturator tapes (TOT). The success rate for both are similar; 1 year continence rate = 85% and 5year rate = 70%. Its effectiveness is reduced if previous continence surgery had been done. As there is no available long term data on TOT, it cannot be routinely recommended as a 1st line surgical treatment-unless there is a contraindication to entering the retropubic space- unrepaired hernia, vascular anomalies.
Burch colposuspension and Marshall Marchetti Krantz (MMK) are equally as effective as sling procedures. However, MMK has the risk of osteitis pubis (2.5%) and hence rarely used nowadays. The success rate at 1 and 5 years is similar to TVT. As TVT can be done under local or regional anesthesia and is associated with shorter: surgery, hospital stay and recovery time it is now the preferred 1st line surgical option. Autologous rectus fascia slings are an alternative to synthetic material (polypropylene) mesh in TVT.
Bulking agents using collagen, silicone or fat injections can be considered if conservative measures fail. Woman should be informed that repeated injections may be needed to achieve efficacy and that efficacy diminishes with time. it’s success is limited for short periods of time – up to 50%.
Posted by A H.
AH
a) A woman should be referred for specialist intervention when first line treatment has failed. Further investigations may be necessary to reach a definitive diagnosis and plan treatment by a suitably trained
specialist.
Pelvic organ prolapse discovered on examination should prompt referral.Surgical repair has a low success rate for relief of incontinence, but will result in improved quality of life and sexual function,reduced discomfort and prevent decubitus ulcers.
A distended bladder after voiding needs specialist intervention for diagnosis using ultrasound and urodynamics, followed by appropriate treatment.
Haematuria requires prompt referral.Macroscopic haematururia in any patient, microscopic haematuria in a woman over 50 years old, or haematuria associated with recurrent urinary tract infection should be at least be minimally be investigated by cystoscopy and possible biopsy. Suspected malignancy of the urinary tract should also be referred.
Referral should be considered if urinary incontinence is associated with bladder or urethral pain, voiding difficulty or faecal incontinence. There may be a neurological cause for some of these symptoms and joint care with the neurologist may be necessary.
Surgery for a benign pelvic mass may improve symptoms and referral will be necessary. Suspicion of a urogenital fistula, especially in a patient who recieved radiotherapy or had surgery for pelvic malignancy or endometriosis should also prompt referral.

b) Stress urinary incontinence (SUI) can be treated with varying degrees of success by conservative, pharmacological or surgical methods as well as by the use of mechanical devices.

Weight loss in an obese patient, cessation of smoking, and treatment of cronic cough and constipation can provide symptom relief in up to 50%.
Pelvic floor muscle exercises (PFME) under a physiotherapist\'s supervision and undertaken for 15 to 20 weeks can produce a cure or symptom improvement in 27 to 80%. Additional use of biofeedback, weighted cones or electrical stimulation does not improve results.
Duloxetine, a combined serotonin and noradrenine reuptake inhibitor, given in a twelve hourly dose of 40 mg can be used as second line tretment after counselling the patient about side-effects. It results in improved quality of life in patients who are not fit for, or does not want surgery.
Phenylpropanolamine, an alpha-adrenergic agonist, gives similar success as PFME.
The gold standard of surgical treatment of SUI is Burch colposuspension which gives a success rate of 85% at one year and 70% at five years. Tension free vaginal tape(TVT) has similar success as Burch colposuspension, but there are no long term results. Benefits of TVT are that it can be done under local anaesthesia,as a day case and in patients who had previous bladder neck surgery.
Anterior colporrhaphy as a treatment for SUI has a poor success rate of about 37 % at five years.
Needle suspension has short term success comparable to Burch, but poor long term success of about 18%.
Transobturator foramen tape (TOT) is an alternative to TVT but long term results are not available.
Intramural bulking agents is a suitable option when coservative treatment has filed but is less efficacious thn TVT and repeat injections are required.
ARtificial urinary sphincter is useful in some cases but longterm follow-up is required
Posted by sofi S.
From history we can determine some symptoms where referral to hospital specialist is required, as woman with persistent pain either bladder or urethral pain and her urine analysis and culture are normal require referral , and if incontinence is continued may indicating fistula especially if she have in her history clue support this suspicion such woman with recent complicated delivery or hysterectomy. Although, more examination and investigation may be required, referral will be considered. In addition, woman has also history of faecal incontinence.
Referral required if woman has history of recurrent UTI or voiding difficulty (for example incomplete emptying bladder or hesitancy) and measurement of residual volume post voiding either by abdominal ultrasound or in out catheter reveal more than 50 ml.
Consideration for referral also for any woman with history of failed previous incontinence surgery as this woman have low success rate of conservative management and further management required to be discussed with specialist urologist. Any woman with history of previous pelvic cancer surgery or previous pelvic irradiation consideration for referral is also required because of highly possibility of complicated incontinence.
Referral is considered if pelvic mass discovered in abdominal or pelvic examination and it is likely to be benign such as fibroid, which may cause inconstance by pressures on bladder. But urgent referral if the mass suspected to arise from urinary tract. If bladder is palpable after voiding referral is required
Part of examination for woman with incontinence is examination for pelvic organ prolapse, and referral is indicated in any woman with symptomatic prolapsed visible at or below vaginal introitus
If visible macroscopic haematuria detected during urine analysis require urgent referral within 2 weeks similarly if urinary dipstick with microscopic hematuria require for aged 50yr or more or 40yr or more if with recurrent or persistent UTI.
Referral can be by woman request especially if symptoms affect her quality of life or and if conservative management such as bladder drill for urge incontinence at least 6 weeks or pelvic floor exercise for stress incontinence failed after at least 3 months
B.
I will advice her to reduce fluid intake and reduce weight if her BMI over 30. She can use intra-urethral or intra-vaginal device to prevent leakage during physical exercise but not routinely.

First line treatment is pelvic floor exercise. Cure rate vary widely from 20% to 85%, as the success may depend on severity and women motivation, it is recommended to be done with specialist therapist. For at least 8 contractions, 3 times daily for at least 3 months. If women could not contract during digital assessment of pelvic muscle contraction (using Oxford/PERFECT score) electrical stimulation and/or biofeedback can be considered.
Medical treatment, Duloxetine, can be offered as second line treatment in woman unsuitable to, waiting or refuse surgery. Although it has up to 60% cure rate which is dose dependent it has depilating adverse effects most frequently nausea and loss of libido.
If failed conservative management, I will offer her surgical treatment unless woman not complete her family or unfit for surgery. Mid-urethral tape using bottom up approach with macroparous type 1 polypropylene meshes like Tension-free vaginal tape (TVT) has continence rate of 80% and improvement rate of 90%. In majority of cases used as day case surgery without general anaesthesia and it is cost effective, but can associated with complication such as bladder perforation 9%. It can also causes de novo detrusor over activity. Alternative surgery with same sucess (Burch) open colposuspension,with abdomianl approach has continence rate of 85-90% at one year and 70% at 5 year. Complication such voiding difficulty, posterior genitourinary(enetrocele,rectocele) , prolapse, ureteric injury and de novo detrusor over activity, but there efficay only 60% if done after previous failed contance surgery and that is not the case with TVT which can have same sucess even when done after failed other containce surgery.
the autologus rectus fascial sling are also alternative to TVT , it carry same contince rate but long term failure rate of 20%. Transobturator tape , can be an option but there is no evidence on long term outcome but can be option if entering to retropubic space is contraindicated for instance vascular abnormality or unrepaired hernia. Similarly, synthetic slings using top-down can be alternative but woman should counsel regarding lack evidence on longterm otcome
Intramural bulking agent such as collagen or silicon but not autologus fat or polytetrafluroethylene can be offered to women if conservative mangment fail,it injected in periurethral tissue around bladder neck and proximal urethra, it has continence rate 48%and an improvement rate of 76%. It has low morbidity so may have a role if other procedures have failed example when there is interinsic sphincter deficiency or can be considred in old fragile lady. Repeat injections may be required and the efficay diminshes with time .
Artificial sphincters has acure rate of 80% and improvemt of 90% , can be successfully used after previous failed contince surgery but risk for need of furhter surgery for cuff erosion or malfunction is 17% may require up to 2 revisions over 8 yrs, so life long follow up required.
Posted by PAUL A.
M
(a)A woman with suspected underlying malignancy what will make you suspect malignancy? from urinary tract should be urgently referred (within 2 weeks).
Woman aged 50 and above with microscopic haematuria or with macroscopic haematuria or with persistant /recurrent UTI with microscopic haematuria may also suggest underlying tumours/urinary tract pathology and needs immediate specialist referral (1) .
If she has a urogenital prolapse she may should she or should she not? needs a specialist as she may want a prolapse repair.
If she has associated neurological signs and symtoms like what? she will need a specialist neurological referral.
If she has a palpable bladder on examination after voiding this may suggest significant residual and need for further investigation and need for specialist referral (1) .
Women with bladder pain or uretheral pain (1) should be considered for referral as may be due to bladder pathology like interstitial cystitis.
If bladder symptoms associated with faecal incontinence (1) may suggest generalised muscular problems and need for specialist referral.
If suspected voiding dysfunction like poor stream (1) may need to exclude urinary tract/bladder pathology and needs for specialist referral.
Any suspected urinary genital fistula what will make you suspect a fistula? need uro-surgical referral for diagnosis and treatment.
Any previous surgeries for urinary incontinence/ pelvic floor surgeries and previous pelvic cancer surgery (or) pelvic irradiation needs specialist input (1) .
Any suspected benign pelvic mass will also need specilaist referral to exclude underlying cause.
Patients quality of life affected and/ non responsiveness of initial management (1) will need specialist input for further investigations and treatment.

(b)
First line treatment option is supervised pelvic floor muscle training(PFMT) lasting atleast for 3 months and atleast 8 contraction 3 times a day.
Before commencing PFMT, pelvic muscle contractions should be assessed digitally to ascertain feasibility of PFMT.
Electrical stimulation and biofeedback is not recommended with PMFT unless the woman cannot actively contract the pelvic muscles.
PMFT has a very good sucess outcome what is the success rate? with minimal intervention and no surgery and patient ownership of treatment, lack of motivation and non compliance of treatment may lead to failure of treatment.
Surgical treatment option include tension free vaginal(TVT) tape \'bottom-up\' using macroporous(type1) polypropelyene mesh which has a sucess of 85-90% continence rate over 5 years (1) .
Open colposuspension is an alternative with similar sucess rates to tension free tapes and more long term data available (1) .
Retropububic \'top-down\' like transobturator tape may be used with explanation to patient as long term data not available but short term sucess similar to TVT (1) .
Laparoscopic colposuspension is not recommended would you offer it? and periurethral bulking may need repeated treatment and efficacy diminishes with time and may not be suitable for young woman ? success rate .
Duloxetine is not recommended (1) ? success rate as first line treatment but may be used as second line as an alternative to surgery in patient who do not prefer surgery or not suitable for surgery with side effect profile like nausea, headache and insomnia.
Other procedures like anterior colporraphy, paravaginal defect repair, needle suspensiona and Marshall-Marchetti Krantz procedures are not recommended so why mention them if you would not offer them? .
An artificial urethral sphincter is only recommended if previous surgeries have failed and need long term followups.
Posted by PAUL A.
Sunday\'s answers

a) Women with urinary incontinence should be referred for hospital specialist intervention when they have tried conservative measures and failed- such include change of lifestyle int erms of reducing or cutting down tea and caffeine, appropriate exercise/ pysiotherapy, weight loss and appropriate intake of fluids. They should have been screened and treated for UTI as well. Secondly a failed medical management (1) by the GP would warant such referral and in such situation when the GP is unsure of the diagnosis or in the presence of other urinary symptoms such as heamaturia particularly in the elderly patients (1) or major urogenital prolapse contributing to the symptoms
Previously failed surgical management of urinary incontinence (1) would also warant a referrel to secondary care and those with previous history of urogenital or renal pathologies e.g urethral diverticulum or those with medical problems such as diabetes due to fact that such underlying medical or surgical problem may be contributing significantly to their symptoms. At times some patients demands immediate referral from their GPs to secondary care- such patients should be educated on the neeed to have their symptoms managed in the first instance in the community but their choice should berespected (1) if they are adamant. there will be features in the Hx, examination, investigations, initial diagnosis and woman’s wishes. See good answer above

b) Treatment options for stress incontinence include; Surgical ,medical ( some instances). The surgical method include; DO NOT NUMBER YOUR ANSWER
1.Burch colposuspension which can be done either by laparoscopy or open method with similar success rate this is not correct – see NICE guidelines / NOTES about 80-90% and continence rate of about 65-70% 5 years after.
2.Transvaginal tape(TVT) which is now considered as the gold standard with similar success rate of 80-90% and 65-70% continence rate after 5 years (1) compared with Burch colposuspension. The procedure take less time to do and can even been done under local anaesthesia (1) .
3.Transobturator tape (TOT)- slightly lesser success rate compared with TVT ? EVIDENCE – Long-term data not available .
4.local injection of the bladder neck with bulk agents has been tried with limited success ? success rate .

In patients who are obese, medical unfit or declined surgery Duloxetine table can be tried but with limited sucess rate but further trial awaited trial data already available

See good answer above
.
Posted by PAUL A.
a)
urinary incontinence severly affects the quality of life. Initial detailed assessment of the type of incontinence and precipitating and predisposing factors are enquired. Impact on quality of life is assessed by using generic and disease specific quality of life questionnaire to assess urinary tract abnormalities and medical conditions accurately and to evaluate the therapeutic efficacy NOT ANSWERING THE QUESTION . Previous history of incontinence and surgery for it is an indication for referral. Previous history of pelvic cancer surgery, pelvic irradiation requires specialist referral (1) .
Obstretical history of difficult or operative vaginal deliveries is enquired. Menstrual history of menorrhagia due to fibroid a benign pelvic mass is an indication for specialist referral.On bimanual examination palpable bladder after voiding (1) indicates a need for referral.pelvic floor assessment should be carried routinely. Urine analysis for blood, protein, glucose, leucocytes and nitrites is done. if leucocytes and nitrites are present culture and sensitivity is done. presence of microscopic hematuria in woman aged 50 yrs, visible hematuria, recurrent and persistent urinary tract infection with hematuria in women aged 40 yrs (1) , suspected malignancy needs urgent referral.Other conditions which requires specialist referral are suspected fistula, associated with fecal incontinence (1) or persistent bladder and urethral pain (1) DO NOT WRITE A LIST.
b)
Treatment of precipitating factors, weight reduction will be useful in about 50% of woman (1) . Conservative treatment involves pelvic floor muscle training with a hospital phsiotherapist is the first line of treatment for atleast three months with 65-75% success rate (1) . Indicated in breast feeding women, less than six months of post partum, prior to surgical treatment. Medical treatment with Duolxetine has significant improvement used as alternative to surgery NOT an alternative to surgery after counselling about the adverse effects. Surgical treatment : benefits and risk are explained, Pre operative urodynamic investigation is carried out if there is previous failed surgery, mixed incontinence, neurological disease is suspected.
Burch colposuspension :replacement of proximal urethra into abdominal cavity by suspending para vaginal tissue to ipsilateral ileopectineal ligament.cure rate of 90% at 1 yr, 70% at 5 and 10
yrs (1) .complications include voiding difficulties, detrusor overactivity and enterocoele formation (1) . Mid urethral tape procedure TVT increases urethral pressure, a bottom up procedure using macroporous poypropelene mesh tape. it has got cure rate of 85% at 5 yr (1) with no long term complication do you know of any operation with NO long-term complications?? (-1) . Used in women with previous colposuspension can it not be used in women without previous surgery? . Convention sling procedure is used in women with narrow vagina, Intrinsic sphincter deficiency with success rate similar to colpo suspension. Anterior colporraphy with badder neck buttress suture is done in women with prolapse where pubocervical fascial defects are corrected. long term outcome is poor, 5yr cure rate is 40% you will repair prolapse and undertake a different operation for incontinence . Peri urethral injection with glutaraldehyde cross linked collagen ,short term benefit is 75% but needs repeated injection (1) ,used in elderly frail, unsuitable for surgery. Artificial sphincter in women with intrinsic sphincter deficiency has got 100% cure rate there is NO operation with a 100% success rate, let alone cure rate (-1) but high complication, needs life long follow up. Marshall Marchetti Kruntz procedure has high cure rate Of 90% but complication of osteitis pubis has decreased the popularity should not be offered . Laparoscopic colposuspension has showed no signficant difference in outcome than open colposuspension not true . other procedures like needle suspension procedures, mechanical devices
do not have good evidence. see Good answer above
Posted by PAUL A.
RnRn

A.
After ruling out underlying causes such as recurrent urinary tract infections, first line treatment of incontinence are simple interventions you were not asked about treatment . In urge incontinence women are advised to avoid bladder irritants like caffeinated drinks, alcohol and smoking. Voiding diaries are used to alter habits of fluid-intake. This can improve symptoms dramatically, even though response after 3 years may be 40% only. In stress incontinence women are advised to reduce weight if obese, alter diet to avoid constipation and avoid smoking. Combined with physiotherapy for pelvic floor exercises this can improve symptoms in 60% of women. Only those not responding to simple interventions should be referred to the hospital (1) . Suspicion of sinister underlying cause (pelvic mass, haematuria (1) ) should be referred straight away. Likewise those with significant prolapse as underlying cause, as response to conservative management is expected less good. Those who have a presentation of mixed or complicated incontinence complaints will also benefit from specialist referral, to determine best approach.
there will be features in the Hx, examination, investigations, initial diagnosis, response to treatment & woman’s wiahes
B.
Initial treatment are life-style changes with pelvic floor exercise ? success rate . Women with prolapse whose symptoms respond well to a pessary, who are keen to avoid further intervention, may wish to continue this. Medical management with duloxetine 20 mg bd is hampered by side-effects (nausea, constipation, visual blurring) and not 1st or 2nd choice (1) ? success rates. Most other treatments involve surgery, and exact success rates are not entirely clear good data available from trials due to techniques varying amongst surgeons. Suspension procedures ( Marshall-Krantz not recommended , Burch – requiring abdominal approach) and TVT all have similar rates of success (89% 1 year, 82% 5 years) (1) , new-onset urge problems (8-12%) and voiding problems (8-10%) (1) . Results and risks for Trans-obturator tape (1) long-term data not available (TOT) seem to be similar to TVT. Anterior repair is less invasive but though short term success may be good, it is <40% after 5 years not recommended for stress incontinence . Most other procedures have more or less good short term success rates what does this mean? with poor long term response, but have as advantage their relative simplicity, making it attractive in women who are less fit for surgery. Amongst these are peri-urethral bulking agents ? success rates (expensive; silicone or collagen) and needle suspension with stamey needles. Use of diversion procedures, neo-bladders or artificial sphincters is highly specific. Artificial sphincters have good success rates what is good? , but these are compromised by many complications like erosion & infection requiring further intervention in up to 50% of women. Permanent catheterization is most suitable for those who are poor surgical candidates. Silicone catheters, preferably suprapubic, must be used and may be troubled by recurrent/chronic infection and blockage/leaking. see good answer above
Posted by PAUL A.
Part A
Women should be offered hospital referral for further investigatioons to differentiate between detrusor overactivity and urinary stress incontinence. I she did not improve upon medical treatment or history regard type of incontinence is inconclusive. mid-stream urine analysis to be to rule out infection. Pelvic US scan to be done to exclude a pelviabdominal mass and to measure bladder wall thickness that my suggest interstial cystitis. urodynamic studies ( cystometry) is the gold standard diagnostic tool for type of incontinence. Urine peak flowmetry for bladder neck obstruction, normal >15 ml / sec with total volume 200 ml in 20 sec. Video- cystourothrogram is useful and diagnosis and educational purposes.

none of these are criteria for referral. You should consider features in the history (fecal incontinence, previous incontinence surgery / pelvic radiotherapy…), examination (pelvic mass), investigations (haematuria), initial diagnosis (neurological disease), response to initial treatment and woman’s wishes

Part B
As she was diagnosed as urinary stress incontinence, the traetment options will depend on the severity of disease and its effect on the quality of life as well as the patient\'s wishes.
Nonmedical treatment for mild to moderate cases include bladder drilling for STRESS incontinence???? (-1) and biofeed back via pelvic exercises, vaginal cones, and Kegel perineometry. Success rate 70 % but decreased markedly after stopping exercise (1) .
Duloxitine which is a serotonin-noradrenalin reuptake inhibitor (SNRI) as medical treatment Option is offered but success rate is low not as first / second line treatment .
Sugical options ar variable and depend up facilities and available expertise. Burch\'s colposuspension a well estblished technique with success rate 85 -90 % after one year and 70% after 5 years (1) .
Tension-free vaginal tape ( mid-urethral support) hase the same success rate (1) like Burch an less invasive. TOT is a sling operation but the long-term success rate not established what about short-term? . Laproscopic colposuspension is another technique but needs facilities and skillful laproscopist to be evaluated should not be offered as lower success rates .
There other tenchniques for failed operations like perurethral bulking agent ? success rates injectable and bladder neck sphincter.
Other surgical techniques that abandoned like Marshal-Marchetti- Krantz not recommended (osteitis pubis) and Kelly plication ( high failure rate) see good answer above
Posted by PAUL A.
a)
Women should be referred for hospital specialist intervention after proper clinical assessment based upon proper and accurate history taking, examination and investigations. History taking is very important and should include:

Urine history taking to determine the nature of incontinence whether it is stress, urge or mixed incontinence. This is not an indication for referral

Medical conditions that may exacerbate or co-exist with UI, neurological disorders, diabetes, respiratory, cardiac or renal disorders. medications that may be associated with UI for example sedatives, and smooth muscle relaxants. A drug history should consider previous medication for UI symptoms you are describing the process of assessing the patient NOT the indications for referral

Obstetric history should include the number and type of deliveries, the woman’s desire for further childbearing, menstrual history and menopausal status should be determined

Surgical history, Previous surgery for UI or for pelvic organ prolapse may complicate treatment and make diagnosis more difficult

Assessment of the social and functional impact of UI, desire for treatment and expectations


Clinical exam is required to assess fitness for surgery, mobility and dexterity, exclude abdomino pelvic masses and palpable bladder, inspect external genitalia for dermatitis due to chronic exposure to urine, demonstrate SI. Speculum examination for prolapse. Bimanual examination to detect pelvic masses


Initial investigations should include completion of a voiding diary, urinalysis to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine, estimation of post void residual volume by bladder scan or catheterization, Urodynamic studies are indicated when there are multiple symptoms, voiding disorder (1) , before surgical managaement and after previous failed incontinence surgery (1) . Cystourethroscopy and dye test if fistula is suspected


There is a wide range of indications for referral why are you only starting to answer the question now? as failed conservative or medical treatment, microscopic haematuria, visible haematuria, recurrent or persisting UTI and suspected malignancy of the urinary tract DO NOT WRITE A LIST .
Also, symptomatic prolapse, persisting bladder or urethral pain (1) , clinically pelvic masses or palpable bladder after voiding, associated faecal incontinence suspected neurological disease, symptoms of voiding difficulty, suspected urogenital fistulae and failed previous continence surgery, previous pelvic cancer surgery, previous pelvic radiation therapy do not write a list .


b)
Treatment options that might be offered to a woman with SI include non surgical measures as weight reduction pelvic floor muscle exercises which should be undertaken for 15-20 weeks, physiotherapy is particularly useful in women unsuitable for surgery or reluctant to do surgery, women who did not complete their family, can also be used postpartum and in women with mild stress incontinence. 27-67% (1) of women may improve. However high relapse when discontinued. Other options include biofeedback, electrical stimulation and vaginal cones.

Treatment of predisposing or exacerbating medical conditions such as diabetes, chronic cough or chronic constipation ? success rate .

Duloxetine a combined serotonin and noradrenaline reuptake inhibitor can be used with dose of 40 mg twice daily result in marked reduction in incontinence per week and significant reduction in social embarrassment ? success rate? Not recommended as first or second line .

Mechanical devices as bladder neck support prothesis , continence guards, urethral plugs and meatal devices are not recommended for routine treatment of SI however can be used occasionally for example during physical exersise.


There are a variety of surgical operations used for the treatment of SI, the choice of which depends on whether it is primary or repeated surgery, mobility of bladder neck, maximum urethral closure pressure and the surgeon experience.

Retropubic procedures as Burch colposuspension aiming to replace proximal urethra within abdominal cavity has a continence rate of 85-90% at 1 year and 70 % at 5 years (1) , lower rates if previous incontinence surgery and may fail if low urethral pressure. Complications include de novo detrusor overactivity 17% and voiding dysfunction 10%, eneterocele and rectocele 14% (1) . Marshal-Markchetti Krantz procedure can be complicated by ostitis pubis (2.5%) not recommended

Laparoscopic colposuspension has the advantage of a shorter inpatient stay and rapid return to normal activities, however needs experience and associated with the risks of laparoscopy e.g. bowel injury and 1-10% rate of urinary tract injury lower success rates therefore not recommended .

Sling procedures such as the TVT using prolene mesh at the site of mid-urethra are suitable in cases with low urethral pressure and aim to increase urethral pressure. Suitable for women after colposuspension. Has a success rate of 85-90% at 5 years (1) , however also may fail after previous incontinence surgery. Complications include 8% risk of bladder injury, de novo DO in about 10% and intraoperative bleeding.
YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE Trans-obturator tape can be used with the advantage of avoiding the retropubic space thus minimizing risk of bladder injury, however long term data are not available.


Anterior colporrhaphy aimiming to correct defects in the pubovesical fascia and placement of retropubic sutures (bladder neck buttress) to support bladder neck has a poor continence rates of 66% at 1 year and 37% at 5 years and associated with higher re-operation rates compared to retropubic procedures.

Other surgical procedures include peri-urethral injection of collagen or macroplastique under local anesthesia, don’t have a high success rates, often reserved for patients who are elderly, frail or after multiple failed continence procedures. Often need to be repeated
Posted by PAUL A.
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].
a)Hospital specialist intervention is necessary when urinary incontinence(UI) is associated with microscopic (women > 50yr) or macroscopic hematuria (1) to rule out genital tract malignancy. women with persistant or recurrent urinary tract infection or UI nonresponsive to conservative management require specialist intervention. UI associsted with genital tract prolapse (1) or significant residual urine assessed clinically does not respond to conservative management and hence require referral to specialist. cases with past history of extensive pelvic surgery, pelvic radiotherapy, or continence surgery (1) should be managed by specialist. suspision of pelvic mass (1) or in the presence of neurological features like what? referral is indicated

b)expectant management with reassurance in a women with out significant UI and allying her fears of any major illness will suffice in some patients. Life style modifications like cessation of alcohol, smoking, moderation/cessation of caffiene, weight loss improve the symtoms in some women ? success rates . treatment of precipitating factors like constipation, respiratory illness, urinary tract infection is all that is reqiured in a proportion of patients. pelvic floor exercises if performed correctly and routinely is useful in approximately 40% of patients (1) . biofeedback has not shown to improve the outcome.
medical treatment of UI involves use of duloxitine ( 5HT and noradrenaline reuptake inhibitor) it is given in a dose of 40mg twice daily. inital trials have promising results however robust evidence is not available for its longetrm use not recommended as first or second line . surgical tratment is the main stay when conservative management fails. primary surgery carries the maximum chance of success, hence choice of surgery should be carefully made. Burch colposuspension (attaching the paravescical and paraurethral fascia to the iliopectineal ligament ) has a success rate of 85-90% (iimediately) and 70% at 5 yrs (1) . complications with this procedure include, voiding difficulties(10%), prolapse(enterocele/rectocele)17%, denovo detrusor overactivity 15% (1) . the marshall-marchetti krantz operation not recommended (suspension of the paravescical and para urethral fascia to the periostium of the pubic bone) is rarely done inspite of a success rate of 85% because of a 2.5% chance of osteitis pubis, also the success at 5 yrs is lower than the burch procedure. laparoscopic colposuspension similar to burch has also been tried with similar/ slightly lower success(75-80%) than burch procedure should not be offered as lower success rates – see NICE guidelines . the advantages of this are less bleeding, rapid recovery, shorter hospital stay. disadvantages, long learning curve, long operating time, success less than burch procedure.
anterior repair or paravaginal repair no longer reccommended so why write it given that you would not offer it? for stress UI since the success rate is upto50-60%. sling operation with autologous, heterologous materials no longer reccomended you are wasting time and space writing about operations that are not done. You were asked about those that you would offer expect for tension free vaginal tape(TFT) mostly referred to as TVT it is a porous prolone mesh inserted at the level of of miduretra. the success rates are upto 90% (1) , these sling procedures carry the risk of erosion and migration of the sling over a period of time. TFT may be recommended for patients with failure of continence surgery why not as a primary procedure??? . needle procedures have a success rate of upto 85-90% but are no longer recommended just answer the question because of the risk of erosion and migration. periuretral injections of collagen gives a succes rate of upto50% but a high failure rate by 5 yrs (1) , hence not recommended. other procedures like artificial sphincter insertion involves elaborate surgery with success in upto80% of women but carries significant morbidity and reoperation rate of 17% you have wasted a lot of time and space and may find you do not have enough time to complete the paper .
Posted by PAUL A.
a) Urgent referral is indicated if microscopic haematuria in above 50 years of age, visible haematuria, recurrent UTIs with microscopic haematuria (1) in 40 years of age or above, suspected mass from urinary tract. In all these its crucial to rule out renal tract malignancy. Symptomatic prolapse and palpable bladder (1) after voiding needs hospital referral as further investigations and surgery may be indicated.
Hospital referral should be considered in previous continence surgery (1) , previous cancer surgery (1) pelvic malignancy , previous radiation surgery as they can be associated with urogental fistula. Suspected benign abdominal or pelvic mass (1) needs further investigation and surgery. Faecal incontinence, neurological disease might need referral to specialist for multidisciplicary care.
Bladder pain or urethral pain (1) may need Cystourethroscopy to rule out interstitial cystitis and urethral divertiulum respectively.

b) Treatment options for Stress incontinence are life style modifications, surgery and/or medical. Life style modifications include to reduce BMI if more than 30 by regular exercise and diet control. Dietician referral may be beneficial ? success rate . Regulate fluid intake of 1.5 to 2 litres per day. Supervised pelvic floor exercise for atleast 3 months and it needs physiotherapy referral ? success rate . Treat associated symptoms like cough, constipation. Advise to stop smoking as it has adverse effect on bladder and urethral sphincter.
Surgery is the mainstay of treatment. Burch Colposuspension and Tension free vaginal tape (TVT) has similar efficacy. Choice is dependant on patient selection criteria and operator expertise. Burch colposuspension has 85-90% continence rate at 1 year and falls to 70% at 5 years (1) . TVT has continence rate of 80%, improvement rate of 90% and efficacy falls over the time (1) . Other suprapubic procedures like Marshall krantz procedure , paravaginal repair and laparoscopic colposuspension\'s not recommended efficacy is unclear. Anterior colporrhaphy is less succesful if done as an operation for incontinence. It is ideal for prolapse without incontinence so would you offer to a woman with incontinence?? . Periurethral bulking injectable agents are considered if all other therapies are failed. Its efficacy is only short term therefore needs repeated injections ? success rate? You were specifically asked in the question . Artificial sphincter is considered in intractable incontinence where all other treatments are failed. It has high morbidity and repeat surgery rate of 17%. Urinary diversion and incontinence pads are other options in refractory cases.
Medical treatment with duloxetine should not be considered as first line due to it side effects. It should not be routinely used as second line. It is considered if the patient is not fit for surgery or declines surgery after proper counselling about its side effects (1) . Estrogen replcement in postmenopausal women improves subjective measures of urinary incontinence but not objective measures would you offer it? .
Posted by PAUL A.
Urinary incontinence can be managed in the community. (a) Discuss when women should be referred for hospital specialist intervention [10 marks]. (b) Discuss the treatment options that you would offer to a woman with urinary stress incontinence and their success [10 marks].
A) Urinary incontinence has a very high incidence and often can be managed in the community by conservative management not necessary .

The patients need to be referred if the symptoms do not respond to conservative management (1) .

Incontinence due to fistula which manifests as continuous leaking of urine needs immediate referral (1) .

Urge Incontinence with hematuria (1) needs urgent referral since it can be a feature of malignancy of the bladder or a calculus in the urinary tract.

Stress incontinence not responding to weight reduction, pelvic floor exercises should be referred presume this is the conservative treatment mentioned earlier . In a patient who has not completed her family or does not want surgery or high risk for surgery, Duloxetine can be tried and referred if all these conservative measures fail.

Urge Incontinence can be managed with Bladder Drill and medically with Anticholinergics namely Oxybutynin, Tolterodine, Solfenacin etc and referred if the patient does not respond.

Patients with Mixed incontinence not indication for referral will have to be referred for Urodynamics and specialist input.

Incontinence due to nerological problems (1) should be referred.

B) The initial management would be changing their lifestyle with weight reduction, reduction in caffeine and alcohol intake ? success rate .

Pelvic floor exercises should be offered. 60% respond (1) to pelvic floor exercices.

In a patient who has not completed her family,not willing for surgery or high risk for surgery, Duloxetine is started with a success rate of about 50% you will not use it in a woman who is planning a pregnancy

In those in whom conservative methods have failed, retropubic sling procedure -The Tension-free vaginal tape is offered with a 80-90% success rate (1) .
The Burch colposuspension has a similar success rate (1) , the long term results are known, but needs an abdominal incision, can be done laparoscopically not recommended .
The Transobturator Tape has a higher complication rate and a lower success rate (1) long-term data not available than these procedures according to latest data.
The peri-urethral injections have a lower success rate of about 60%
and the efficacy diminishes with time (1) .
The MMK procedure is not recommended due to high rate of complications.
Posted by PAUL A.
NSK

A)
Referral will depend on findings during history,examination and initial investigation. Urgent referral is needed if frank or microscopic hematuria present. Microscopic hematuria in woman at least 50 years old maybe the first sign of bladder tumour (1) . Presence of recurrent or persistent urinary tract infection (UTI) with hematuria in a woman at least 40 years old must be referred urgently. If a pelvic mass is suspected, arising from the urinary tract (1) what if mass is not from urinary tract?, urgent referral is needed.
Referral should also be made for woman presenting with symptomatic prolapse that is visible at or below the introitus (1) . If a palpable bladder is noted post micturition on bimanual palpation or physical examination – she too should be referred for specialist input. This denotes voiding dysfunction with significant post void residual volume (1) .
Referral should be considered in a woman with clinically benign pelvic mass, persistent bladder or urethra pain (1) or incontinence associated with fecal incontinence (soiling) (1) do not write a list . In a woman with previous continence or pelvic cancer surgery (1) , referral is considered as treatment of incontinence may prove difficult in them. This should also be considered if they have had radiotherapy treatment previously. In suspected neurological disease or urogenital fistulae what will make you suspect a fistula? , referral is considered for specialist input. Woman with voiding difficulties should be reviewed by a specialist as further investigation is needed. Referral to hospital for specialist input should always be considered if initial community management or treatment fails (1) .

B)
Treatment begins with pelvic floor exercises for at least three months. She should be referred for physiotherapist input to teach appropriate pelvic floor exercises and induce patient motivation. 50% women note an improvement of their symptom with PFE alone (1) . However, once stopped, symptom can recur. Lifestyle changes such as weight loss in woman with BMI>30 and reducing high fluid intakes to 1.5L/day helps improve symptoms in up to 50% women (1) .
Drug therapy with duloxetine, a Serotonin Noradrenaline Reuptake Inhibitor (SNRI) has been used. However, NICE has recommended it should NOT be used as 1st or 2nd line treatment for SUI. It should be considered as a 2nd line treatment in women who refuse or is unsuitable for surgical intervention (1) . Its main side effect is nausea, which tends to improve over several weeks. It reduces incontinence in up to 50% women and the affects are mainly seen within 1-2 months of use. If no response is seen after this period, it is probably not worthwhile to continue this treatment.
Systemic HRT has no benefit in improving stress incontinence and is not recommended so why write it? .
Incontinence pessary –such as ring, dish has also been used. It acts by compressing urethra against upper portion of the posterior symphysis pubis. It provides continence in up to 40% woman. However, several studies demonstrate only short-term efficiency (1 month).
Surgical treatment is only considered if conservative measures fail. Options include: tension free vaginal tapes (TVT) and transobturator tapes (TOT). The success rate for both are similar; 1 year continence rate = 85% and 5year rate = 70% (1) do you have 5 year data for TOT?. Its effectiveness is reduced if previous continence surgery had been done. As there is no available long term data on TOT, it cannot be routinely recommended as a 1st line surgical treatment-unless there is a contraindication to entering the retropubic space- unrepaired hernia, vascular anomalies.
Burch colposuspension and Marshall Marchetti Krantz (MMK) are equally as effective what is the success rate? as sling procedures. However, MMK has the risk of osteitis pubis (2.5%) and hence rarely used nowadays would you offer it?? . The success rate at 1 and 5 years is similar to TVT (1) . As TVT can be done under local or regional anesthesia (1) and is associated with shorter: surgery, hospital stay and recovery time it is now the preferred 1st line surgical option. Autologous rectus fascia slings not recommended are an alternative to synthetic material (polypropylene) mesh in TVT.
Bulking agents using collagen, silicone or fat injections can be considered if conservative measures fail. Woman should be informed that repeated injections may be needed to achieve efficacy and that efficacy diminishes with time. it’s success is limited for short periods of time – up to 50% (1) .
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AH
a) A woman should be referred for specialist intervention when first line treatment has failed (1) . Further investigations may be necessary to reach a definitive diagnosis and plan treatment by a suitably trained
specialist.
Pelvic organ prolapse discovered on examination should prompt referral depends on symptoms / extent of prolapse .Surgical repair has a low success rate for relief of incontinence, but will result in improved quality of life and sexual function ? evidence ,reduced discomfort and prevent decubitus ulcers.
A distended bladder after voiding (1) needs specialist intervention for diagnosis using ultrasound and urodynamics, followed by appropriate treatment.
Haematuria requires prompt referral.Macroscopic haematururia in any patient, microscopic haematuria in a woman over 50 years old (1) , or haematuria associated with recurrent urinary tract infection should be at least be minimally be investigated by cystoscopy and possible biopsy. Suspected malignancy of the urinary tract should also be referred what will make you suspect malignancy? .
Referral should be considered if urinary incontinence is associated with bladder or urethral pain (1) , voiding difficulty or faecal incontinence (1) . There may be a neurological cause for some of these symptoms and joint care with the neurologist may be necessary.
Surgery for a benign pelvic mass may improve symptoms and referral will be necessary (1) . Suspicion of a urogenital fistula what will make you suspect a fistula? , especially in a patient who recieved radiotherapy (1) or had surgery for pelvic malignancy (1) or endometriosis should also prompt referral.

b) Stress urinary incontinence (SUI) can be treated with varying degrees of success by conservative, pharmacological or surgical methods as well as by the use of mechanical devices.

Weight loss in an obese patient, cessation of smoking, and treatment of cronic cough and constipation can provide symptom relief in up to 50% (1) .
Pelvic floor muscle exercises (PFME) under a physiotherapist\'s supervision and undertaken for 15 to 20 weeks can produce a cure or symptom improvement in 27 to 80% (1) . Additional use of biofeedback, weighted cones or electrical stimulation does not improve results.
Duloxetine, a combined serotonin and noradrenine reuptake inhibitor, given in a twelve hourly dose of 40 mg can be used as second line tretment not recommended as second line – see notes / NICE guidelines after counselling the patient about side-effects. It results in improved quality of life in patients who are not fit for, or does not want surgery.
Phenylpropanolamine, an alpha-adrenergic agonist, gives similar success as PFME.
The gold standard of surgical treatment of SUI is Burch colposuspension which gives a success rate of 85% at one year and 70% at five years (1) . Tension free vaginal tape(TVT) has similar success as Burch colposuspension, but there are no long term results ?? for TVT?? . Benefits of TVT are that it can be done under local anaesthesia,as a day case (1) and in patients who had previous bladder neck surgery.
Anterior colporrhaphy as a treatment for SUI has a poor success rate of about 37 % at five years.
Needle suspension has short term success comparable to Burch, but poor long term success of about 18%
would you offer these options? .
Transobturator foramen tape (TOT) is an alternative to TVT but long term results are not available what are short-term results? .
Intramural bulking agents is a suitable option when coservative treatment has filed but is less efficacious thn TVT and repeat injections are required ? success rate .
ARtificial urinary sphincter is useful in some cases but longterm follow-up is required
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From history we can determine some symptoms where referral to hospital specialist is required, as woman with persistent pain either bladder or urethral pain (1) and her urine analysis and culture are normal require referral , and if incontinence is continued continuous may indicating fistula especially if she have in her history clue support this suspicion such woman with recent complicated delivery or hysterectomy. Although, more examination and investigation may be required, referral will be considered. In addition, woman has also history of faecal incontinence (1) .
Referral required if woman has history of recurrent UTI or voiding difficulty (for example incomplete emptying bladder or hesitancy) and measurement of residual volume post voiding either by abdominal ultrasound or in out catheter reveal more than 50 ml.
Consideration for referral also for any woman with history of failed previous incontinence surgery (1) as this woman have low success rate of conservative management and further management required to be discussed with specialist urologist. Any woman with history of previous pelvic cancer surgery or previous pelvic irradiation (1) consideration for referral is also required because of highly possibility of complicated incontinence.
Referral is considered if pelvic mass (1) discovered in abdominal or pelvic examination and it is likely to be benign such as fibroid, which may cause inconstance by pressures on bladder. But urgent referral if the mass suspected to arise from urinary tract. If bladder is palpable after voiding referral is required (1)
Part of examination for woman with incontinence is examination for pelvic organ prolapse, and referral is indicated in any woman with symptomatic prolapsed visible at or below vaginal introitus (1)
If visible macroscopic haematuria detected during urine analysis require urgent referral within 2 weeks similarly if urinary dipstick with microscopic hematuria require for aged 50yr or more or 40yr or more if with recurrent or persistent UTI (1) .
Referral can be by woman request especially if symptoms affect her quality of life or and if conservative management such as bladder drill for urge incontinence at least 6 weeks or pelvic floor exercise for stress incontinence failed after at least 3 months (1)
B.
I will advice her to reduce fluid intake and reduce weight if her BMI over 30. She can use intra-urethral or intra-vaginal device to prevent leakage during physical exercise but not routinely ? success rate .

First line treatment is pelvic floor exercise. Cure rate vary widely from 20% to 85% (1) , as the success may depend on severity and women motivation, it is recommended to be done with specialist therapist. For at least 8 contractions, 3 times daily for at least 3 months. If women could not contract during digital assessment of pelvic muscle contraction (using Oxford/PERFECT score) electrical stimulation and/or biofeedback can be considered.
Medical treatment, Duloxetine, can be offered as second line not recommended as second line – see notes / NICE guidelines treatment in woman unsuitable to, waiting or refuse surgery. Although it has up to 60% cure rate which is dose dependent it has depilating adverse effects most frequently nausea and loss of libido.
If failed conservative management, I will offer her surgical treatment unless woman not complete her family why can such women not have surgery?? Would you want to come to work wetting yourself every time you coughed? or unfit for surgery. Mid-urethral tape using bottom up approach with macroparous type 1 polypropylene meshes like Tension-free vaginal tape (TVT) has continence rate of 80% and improvement rate of 90% (1) . In majority of cases used as day case surgery without general anaesthesia (1) and it is cost effective, but can associated with complication such as bladder perforation 9%. It can also causes de novo detrusor over activity (1) . Alternative surgery with same sucess (Burch) open colposuspension,with abdomianl approach has continence rate of 85-90% at one year and 70% at 5 year (1) . Complication such voiding difficulty, posterior genitourinary(enetrocele,rectocele) , prolapse, ureteric injury and de novo detrusor over activity, but there efficay only 60% if done after previous failed contance surgery and that is not the case with TVT which can have same sucess even when done after failed other containce surgery.
the autologus rectus fascial sling are also alternative to TVT , it carry same contince rate but long term failure rate of 20% not recommended . Transobturator tape , can be an option but there is no evidence on long term outcome what about short-term data? but can be option if entering to retropubic space is contraindicated for instance vascular abnormality or unrepaired hernia. YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE Similarly, synthetic slings using top-down can be alternative but woman should counsel regarding lack evidence on longterm otcome
Intramural bulking agent such as collagen or silicon but not autologus fat or polytetrafluroethylene can be offered to women if conservative mangment fail,it injected in periurethral tissue around bladder neck and proximal urethra, it has continence rate 48%and an improvement rate of 76%. It has low morbidity so may have a role if other procedures have failed example when there is interinsic sphincter deficiency or can be considred in old fragile lady. Repeat injections may be required and the efficay diminshes with time .
Artificial sphincters has acure rate of 80% and improvemt of 90% , can be successfully used after previous failed contince surgery but risk for need of furhter surgery for cuff erosion or malfunction is 17% may require up to 2 revisions over 8 yrs, so life long follow up required.
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A good answer should include the following
(a)

Features in the history
• Symptoms of voiding difficulties or fecal incontinence (1 mark)
• Presence of bladder / urethral pain (1 mark)
• Presence of symptomatic prolapse that is visible at or below the introitus (1 mark)
• Previous incontinence surgery or previous surgery for pelvic cancer or pelvic irradiation (1 mark)
• History of recurrent UTI associated with haematuria in woman over the age of 40 years (1 mark)

Features on examination
• Palpable bladder on bimanual or abdominal examination after voiding (1 mark)
• Presence of mass – either arising from urinary tract or in rest of pelvis – urgent referral (1 mark)

Features on investigation
• Microscopic haematuria if aged 50 years and older or visible haematuria – urgent referral (1 mark)

Initial diagnosis
• Suspected neurological disease or urogenital fistulae (1 mark)

Woman’s wishes
• Woman wishing to consider surgical treatment or requesting referral (1 mark)

Response to initial treatment
• Failed / inadequate response to initial treatment


(b) Treatment options
• Pelvic floor physiotherapy – first line treatment option. Should be undertaken for at least 3 months. 27-67% of women improved or cured (1 mark)

• Medical therapy with duloxetine – reserved for women who decline surgery. Shown to result in a significant reduction in incontinence episodes but not recommended as first / second line treatment (1 mark)

• Retro-pubic procedures like TVT - success rates 85-90% improved or dry at 5 years (1 mark) .

• TVT has advantage of day-case procedure which may be performed under local anaesthesia (1 mark)

• Colposuspension – success rate similar to TVT (85-90% improved or dry at 5 years) (1 mark)

• Major abdominal operation requiring GA and longer hospital stay (1 mark)

• TVT & colposuspension associated with similar risk of detrusor over-activity and voiding dysfunction (1 mark)

• Trans-obturator foramen procedures have similar short-term outcomes to TVT but long-term data not available and women should be informed of this (1 mark)

• Peri-urethral injection of bulking agents such as collagen but women should be informed that success rates (48 – 76%) lower than for procedures like TVT, repeat injections may be needed and efficacy decreases with time (1 mark)

• Most appropriate option and success rate influenced by previous surgery for urinary incontinence (1 mark)
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