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MRCOG PART II ESSAY 276 - Incontinence

Posted by amina  .

A healthy 37 year old woman is referred to the gynaecology clinic because of urinary leakage on coughing. (a) Discuss your initial assessment [12 marks]. (b) She has urodynamic stress incontinence and is considering surgical treatment. How would you counsel her about the role of tension-free vaginal tape in treating her symptoms? [8 marks]

 

 i will ask about duration of her symptoms , whether she have urgency , nocturia  and day time frequency as it points towards overactive bladder . i will ask about haematuria , it needs prompt investigations to rule out renal tract malignancy.

i will ask about voiding dysfunction , any lump in vagina /outside the vagina that gives idea about pelvic organ prolapse .i will ask about dysuria and recurrent urinary infections. i will ask about defecation , constipation , fecal urgency and incontinence as these problems may coexist.

 i will assess  impact of her symptoms on her quality of life . i will explore her concerns , wishes . i will ask about parity , future fertility as subsequent pregnancy can have detrimental effects on continence surgery. i will ask about previous treatment and surgeries , their outcome. smoking is a risk factor , so i will ask about smoking.

i will ask about sexual dysfunction .

i will check her BMI as obesity is a risk factor . obese patients will benefit from weight loss. i will perform abdominal and pelvic examination to look for scars/ incisions of previous surgeries. i will palpate the masses  as ovarian masses , tumors and fibriods can press the bladder. i will check for palpable bladder as it is sign for chronic urinary retention. 

i will do vaginal examination for perineal inflammations. ulcerations due to chronic incontinence . i will check for pelvic organ prolapse , anterior vaginal wall cysts, vaginal scarring due to surgeries.

coughing with full bladder can demonstrate stress  incontinence. pelvic floor contraction and strength should be checked by digital palpation as it will direct future treatments.  

if bowel symptoms , i will do rectal examination to assess anal sphincter tone , rectal tumor/ mass. if suspected neurological patholgy , neurological examination is needed.

 

i will use frequency volume charts and give her bladder diary to fill for 3 days. urine dipstix to detect blood , nitirites , leucocytes , glucose , protien. midstream urine for culture to detect urinary tract infection. postvoid residual volume measurement is carried out after asking her to empty bladder and checking volume of urine by ultrasound. more than 100ml is abnormal indicates obstruction to urinary flow or  hypocontractile bladder. 

quality of life questionarrires will help to know impairement in QOL.

2.  if there is no other patholgy like pelvic organ prolapse  , she is fit for surgery  then surgery is most effective way of treating stress incontinence. i will tell her about the procedure of surgery it elevates  bladder neck and proximal urethra.

. it can be done under local anesthesia hence avoids risks related to general anesthesia. it  is effective treatment with improvement in symptoms in 85-90% of patients. it uses marcoporous polypropylene mesh . it has complications like short term voiding difficulties. bladder perforation ( 9% ) and denovo detruser overactivity.

it can have mesh erosion several years after surgery.

success rate will be less if previous continence surgery failed. i will provide written information. i will discuss alternatives like pelvic floor excercises , colposuspension , transoburator tape procedures. 

 

 

essay incontinence Posted by Reena G.

I will take the  history  in which I will ask about  the onset and duration of symptoms  and how much it is affecting her QOL.  I will ask whether   coughing  is due to any chornic respiratory problem or due to smoking as it will not influence the diagnoses but will affect the management. If  she has any  increase frequency , dysuria  or hematuria  then this may  suggests any Urinary tract problem, any nocturia or urgency or urge incontinence will point towards  detrusor overactivity.i will ask about her obstetrical history in which   parity and mode of deliveries   will be enquired . Any traumatic deliveries   with lump  in vagina will explain the urogenital  prolapse and also I will ask about her future desire of fertility  as this will affect the management.I will also ask about any past history of diabetes , hypertension , any  intake of drug like dieuretics, any past perineal  surgeries  or any treatment she had  for this problem.Her sexual history should also be sensitively explored  as it may have psychological impact on her.

On examination I will check her BMI as obesity is a risk  factor for incontinence and it is modifiable.in general examination I will do chest examination and  in per abdominal examination ,any suprapubic tenderness  and any abdominal  or pelvic mass to be explored. In pelvic examination I will look for any previous scars , any vulval or vaginal mass , perineal excoriation due to incontinence of urine, any deficient perineum. With full bladder , I will look  for any leakage during coughing and confirm USI, will look  for other pathology  like cystocele, uretherocele ,uterine and rectocele  as it could be a coexistent problem.Bimanual examination to be done to find out any ovarian or uterine pathology that is producing urinary symtoms . Digital examination done to  check the pelvic floor muscle strength . Per rectal examination doneif any  associated bowel symptoms. Normal plantar , anal and perineal reflex will rule out neurological  cause if any neurological symptoms present.

In further assessment bladder diary to be given for3 days for frequency and volume charting of micturition . Urine  analyses to be done for possibility of hematuria and infection and MSU to be sent  for culture if UTI detected and cystoscopy to be done if hematuria present to detect  renal tract pathology.Random blood sugar to be done to rule out diabetes. Pre and post micturition USG to be done to detect any residual urine  which may suggests any urinary obstruction . Urodynamic is suggested if  diagnosis is not clear or before surgery.

b)In considering surgical treatment I will tell her about TVT procedure. It is safe and effective  treatment  and time taken and recovery time is short . It is a day procedure and can be done in local and regional anesthesia and thus avoids  anaesthetic complications . The  Success rate is 85-90% and it is reduced if  any past surgery done . The aim of the procedure is to increase the uretheral pressure by using a  polypropylene mesh , macroporous type 1, from bottom  to up .i will discuss about the risks  of  this operation- risk of bleeding during operation, risks of bladder perforation about 9 out of 100, short term voiding difficulties 4.3 out of 100 and new voiding difficulties 5-13 out of 100, risks of  infection &mesh erosion after some years . I will tell her that reported studies( of MRHA  2012) has shown  very less complication except one complication of deterioration of sexual  function (postop 6months )about median of 9.3 %. . I will   tell her  about other alternatives like PFE,  duoloxetine ,will  provide  her information leaflet .

 

incontenince essey Posted by shereen S.

Iwill start by detaliled history about onset and duration of her complain.Is it first time or she had treatment before.Iwil ask about associated symptoms such as frequency and urgency  that may refer to urenary tract infection.Heamaturia and pain refered to urinary system diseases.iwill ask if  incontinence associaten with nucturia  or urgency as it may refere to detrusoer overactivity.Iwill ask about precipatating factors for urodynaminc incontenince such as smoking or lefting heavy object.if this cough is associated with chest infection.her parity and mode of delivery wil be asked as high parity and trumatic vaginal delivery can leads to incontience.iwill ask her about intend for future pregnancy asit affect the mangemnet.i will ask about any lumpcoming from the vagina as prolapse can affect the management.Iwil ask  her about impact of the incontenince on her quality of life.iwill give her quality of life questionner which include effect of this inconteninance on her self esteem,sexual life or leading to restriction of her regular physical activity. 

i will check her MBI as obesity preciptate for urodynamic inconteince.chest examination for chest infection.abdominal examination to check any palpable mass.if the bladder is palpable or not and any ternderness noted as it refere to chronic infection.i will make pelvic examination to check vulval irritation from drippling of urine.with full bladder i will ask from the women to cough to see drippling of urine.i will check presence of uterine prolapse cytocele or rectocele.iwil make bimanual examination to check any adenxyal mass.digital examination to check for  strenghth of pelvic floor muscles.per rectal examination if there are bowel symptoms.

i will ask for urine analysis for infectionand  msu culture if there is an infection.

i will request estimation of residual urine in the bladder by pre and post mictuartion u/s.

Then i will give her bladder diary to fill it for 3 days to check her fluid intake including beaverage such as coffee and bear.i will ask her to write also frequency and roughly estimated amount and time of urine/day. -

B) Iwill expalin first that TVT is a safe and effective treatment for stress incontienince.sucess rate for it about 85-90% .It van be done by regional or local anasthesia.i will explain the operation as it will suport mid part of the urethera and will increase the uretheral pressure to prevent urine leakage.i will also explain the complications of TVT as it can lead to9% . risk of bladder injury.and there is a small risk of ntraoperative bleeding.Also.i will inform her that postoperative pain are asssessed after 6 monthes in large study

are estimated to be0.0% (0.0-0.5)

there are small risk of erosion of the tape about1.1%.while sexual dysfunction can reach 9 %

i will inform her that until waiting for surgery she can use Duloxitine 40 mg twice/day to decrease incontince .

Finally , i will give her written information about the operation and comlication .counselling detailes will be documented in her file.

essay incontinence Posted by MONA V.

 

a)       Initial assessment involves history of duration of symptoms, amount of urine leak  and effect on quality of life.  Ask about relation to cough, exercise any urgency and urge incontinence. Ask about symptoms of voiding dysfunction like poor stream of urine and voiding difficulty. Urinary tract infection (UTI) may be associated and symptom like frequency of urination, dysuria are asked.  Presence of hematuria would point to  cystitis ,calculus or malignancy in urinary tract needing urgent referral.    Ask for obvious prolapse or mass descending in vagina. Gastrointestinal symptoms like constipation may be present in abdominal mass . Enquire about  nocturia , nocturnal  incontinence and pain on bladder filling .

           Enquire about recent childbirth which could aggravate incontinence and need for      pelvic floor exercises.  Future reproductive intentions asked as surgery avoided if she has plans for further pregnancy. History of smoking causing chronic cough, fluid caffeine coffee intake elicited as lifestyle modification can help treatment.   Examine  BMI as obesity can aggravate incontinence . Look for abdominal masses ,palpable bladder . Speculum examination for prolapse ,cystocele. Examine in full bladder for obvious stress (urinary leak on coughing).    Ask her to maintain a bladder diary for 3 days covering different types of activity. She should note the intake output throughout the day, periods of urgency if any , incontinence so as to identify type of incontinence . Urine dipstick for leucocyte nitrite blood done to rule out UTI . Mid stream urine culture done if symtoms or luecocyte present to diagnose infection. Frank painless hematuria may need referral for cystoscopy. Ultrasound pelvis to be done if any pelvic mass and to note post void residual urine. If symptoms suggest fasting postprandial sugars for diabetes.  Urodynamics sudy need not be done initially for conservative management .

b)      She is told that transvaginal tape (TVT) is a surgical procedure in which a special type of synthetic sling is used to support the urethra and remains permanently in place . Body tissue will grow around it and it is not harmful.  

This procedure can be done as daycare under local or regional anaesthesia. It is 85%  effective over a period of 5 years and less invasive than other procedures.

She will have more control over her bladder symptoms .She is also told about disadvantage like voiding difficulty in 4 out of 100 women and need for intermittent self catherisation . There can be 3-15 % risk of  detrusor instability where she may need to pass urine urgently. There is small risk of bladder perforation also. The procedure is treatment of choice if she wants surgery and symptoms have not resolved despite pelvic floor exercises and lifestyle modification. She is given clear written information about procedure. She is given contact details of support like Continence foundation, incontact.

UDI Posted by Sailaja C.

 

A) History is taken about the effect of incontinence on her quality of life. 

Enquiry is made about other symptoms such as urgency, urge incontinence, frequency and nocturia. History is taken about bowel symptoms such as constipation incontinence of faeces or flatus.

Symptoms of dysuria, urgency and haematuria suggest UTI.

If she has multiple symptoms, the main symptom of concern is noted. History is taken if she has noticed any mass per vagina suggestive of  prolapse of the uterus. 

History is taken about bladder pain. Her obstetric history taken to note her future reproductive intentions and recent child birth.

Information is taken about fluid intake, caffeine and alcohol consumption. 

History is taken about details of any previous surgery performed for urinary incontinence and her concerns about the result of the surgery.

Social history is taken which includes, mobility, dexterity, and access to toilets. History is taken about smoking. 

Examination includes assessment of BMI.

Abdominal and pelvic examination is performed to exclude palpable bladder and palpable abdomino- pelvic mass and  to exclude utero-vaginal prolapse.

Stress incontince is demonstrated with moderately full bladder.

Investigations include urine dipstix for protein, nitrites, leukocytes, glucose, and blood.

She is asked to keep urinary dairy for 3 days to assess fluid intake, episodes of incontince and bladder capacity. MSU is important if the urine dipstix is positive for nitrites and the woman's symptoms suggest UTI.

 

B) 

She should be informed about the surgical technique that knitted prolene mesh tape is placed at mid urethra . Explanation is given that the aim of the TVT is to increase the urethral pressure. This can be done under local anaesthesia as a day care procedure.

She is informed about the success rates of TVT which is about 85 %-95% at 5 years. It has got similar rates of success with colposuspension in achieving dryness which is about 38% for TVT and 40% for colposuspension at 6 months.

Information is given about the complications  of TVT which includes bleeding during the surgery. The other complications include De novo detrusor over activity which is about 3-15 per  100. The rate of voiding dysfunction is 4-5 per 100 cases,  although long term dysfunction is less common. The risk of bladder perforation is about 9 per 100.  She should be informed that the post operative pain or discomfort after six months is almost nil ( according to MHRA report) The long term complication of mesh erosion is about 1in 100  which can present several years after surgery. 

Sexual dysfunction has been noticed after 6 months of surgery in approximately 10 out of 100 of the patients who had undergone TVT. She is given information that about 1-2 of patients out of 100 may require repeat surgery for incontinence after TVT. 

Written information is given about the surgery. 

Essay incontinence Posted by Dr Sanhita  K.

 

A. My initial assessment  of this lady complaining of stress incontinence would include a detailed history regarding the duration and severity of urinary leakage, associated symptoms of urgency, frequency, dysuria and urge incontinence. History of voiding difficulty and urinary leakage during sexual activity should be enquired into .The impact of these symptoms on her quality of life and and mood needs to be ascertained. Obstetric history regarding delivery of big babies, prolonged labour and instrumental deliveries need to be ascertained as denervation injuries during childbirth is associated with stress incontinence. History of previous gynaecological surgery, history of diabetes mellitus and cardiac disease would be taken as the disease or treatment may lead to urinary symptoms. History of medications such as diuretics and use of continence devices need to be taken. She should also be asked about history of smoking and excessive caffeine intake. The menstrual history needs to be taken to elicit history of heavy menstrual bleeding and pressure symptoms as pelvic mass can cause pressure symptoms and incontinence. Any history of red flag symptoms such as haematuria or recurrent urinary tract infection with haematuria needs to be elicited as they would need urgent referral to the urologist.

 

Examination would include assessment of BMI, palpation of abdomen for any pelvic mass or palpable bladder. Per vaginal examination for assessment of pelvic organ prolapse if any and demonstration of stress incontinence on coughing would be done.

A dipstick test for leucocytes and nitrites and a MSU for culture is advised to exclude urinary infection. She should also be advised to complete a bladder diary for 3 days regarding fluid intake, output, episodes of incontinence and activity with which it occurred and any episodes of urgency and urge incontinence. A quality of life questionnaire too needs to be sent to her to assess the severity of her problem.

If incontinence cannot be demonstrated, a pad test can be done for confirmation.

 

B. The woman should be informed about the procedure. She should know that Tension free vaginal tape is a synthetic non absorbable tape which is placed under the middle part of her urethra where it acts like a hammock, supports the urethra and prevents leakage of urine during periods of raised abdominal pressure as during coughing. The tape is well accepted by the body, stays there permanently and tissues grow over it .The chance of objective cure rate is 80-85% at 2 years and subjective improvement is 90%. These results are comparable to colposuspension and  is associated with quicker recovery . TVT  is done as a day care procedure under general or regional anaesthetic. There is a need for cystoscopy during the procedure.. Catheterisation is needed for a few hours after the procedure unless retention occurs .The patient is discharged on the same day with oral analgesics for pain relief. She should not drive for a week, take time off work for2 weeks and avoid intercourse for 4-6 weeks.

The risks of the procedure should be informed to her which include risk of bladder and urethral  injury in 4% cases and haemorrhage or retropubic haematoma in 2% cases. Urinary and wound infection occurs in 2% cases. There is a risk of vaginal perforation and urinary retention needing catheterization.

Long  term complications include voiding difficulties in 2% cases, dyspareunia in 10% women and tape erosion in 1% women There is also a need for repeat surgery in 2-3% women and sensory urgency in 6% women.

Information leaflets documenting the above information and alternative treatments should be provided to her.

Posted by Mahnaz A.
  1. An enquiry should be made about the duration of symptom and associated  frequency, urgency, nocturia or urge incontinence. Any history of heaviness in vagina or diagnosed prolapse is noted. Her associated concerns and fears should be identified. She should be asked whether the symptoms are affecting her quality of life.  Obstetric history should be taken in detail including mode of deliveries and recent delivery which may cause stress incontinence. Gynae history should include any knowm fibroid or ovarian tumour causing pressure symptoms on bladder.  History of smoking, chronic cough, constipation and diabetes  should be ascertained.  Treatment history should be asked and compliance with treatment and any improvement of symptom should be noted. Incontinence surgery and  treatment failure should also be noted. Cervical smear history is enquired.

 

General examination is done including BMI as obesity can cause stress incontinence.  Abdominal examination is done to look for masses such as fibroid and ovarian tumour. Vulva is inspected for any excoriation and cough impulse test done to check for stress incontinence.Spesulum examination is done and checked for prolapse.  Bimanual examination to exclude pelvic mass is important. Smear in collected if due.

Urine is tested for microscopy and culture. Frequency-volume chart is given and explained and advised to maintain for 3 days. An ultrasound is perfomed to assess postvoidal urine volume. A volume more than 50 cc is abnormal. An assessment of perineal muscle contraction and perineal sensation is done.

 

2. The woman should be properly explained about her condition and available treatment options. Pros and cons of all available surgical methods are discussed such as burch coposuspension and  TVT. She should be informed about the procedure of TVT insertion and that it is done under local or regional anaesthesia , so carries less anaesthetic hazards. It is suitable for woman who have had previous colosuspension. The success rate is similar to colposuspention, 85-90% at 5 years. But the success rate is less with history of previous incontinence surgery. The commplications include detrusor overactivity, short term voiding dysfunction, bladder perforation, erosion of the sling and intraoperative bleeding.

All the informations should be provided accurately so that the woman can take an informed decision.

Verbal informations should be supplemented by leaflets.

 

urinary incontinence Posted by Ghida R.

 

A healthy 37 year old woman is referred to the gynaecology clinic because of urinary leakage on coughing. (a) Discuss your initial assessment [12 marks].

I will check for symptoms of urgency, frequency and nocturia as these may point also to an overactive bladder . Hesitancy and poor, intermittent stream are suggestive of chronic urinary retension.  Continuous leak may suggest presence of fistula. Hematuria might refer to an underlying urinary tract lesion(e.g. tumor). History of recurrent urinary tract infection (3 episodes in the last 12 months) will indicate presence of urinary stasis which favours urinary infection. Other symptoms e.g chronic constipation might indicate presence of rectocele and pelvic organ prolapse. Her  daily caffeine and water intake are noted as their excessive intake will worsen the symptoms. I will check her parity and mode of deliveries as difficult vaginal deliveries are associated with increased incidence of pelvic wall relaxation including stress incontinence.Her menstrual history is also checked to ensure she is not menopausal, menopause worsens the symptoms of urgency, and those of pelvic wall prolapsed.  I will enquire about her future fertility plans as further pregnancy may worsen symptoms and can have an impact on surgical repair. I will sensitively enquire about the effect of urinary leak on her sexual life and whether this is affecting her quality of life by use of a questionnaire. This will help to assess the severity of the condition and to assess the improvement in symptoms at a later stage. Associated dyspareunia and lumps can denote pelvic organ prolapsed. Previous pelvic and perineal surgeries or previous continence surgeries should be enquired about, as these may be followed by surgical fistula or may denote the possiblity of lower chance of success in subsequent surgical repair. I should also enquire about smoking and any chest conditons as chronic cough worsens the symptoms and might worsen symptoms.Rectal exam can be done to assess the posterior wall prolapse, to investigate chronic constipation and if there is rectal incontinence.

Physical exam will include assessing her BMI, BMI >30 should be advised to lose weight before any surgical treatment. I will check her abdomen for any palpable mass which will denote an underlying structural pathology. Suprapubic tenderness may denote a urinary tract infection. The patient should be then examined pelvically noting signs of skin irritation due to continuous urinary leak, the anterior and posterior vaginal wall should be checked for presence of fistula, cystocele, rectocele. The uterus should also be assessed for descensus. Urinary leak can be elicited by having the patient cough; this is seen in stress urinary incontinence. A MSU should be sent for analysis of nitrites, leucocytes, red cells, sugar, proteins, bacteria so as to detect any infection. Urine should also be sent for culture and sensitivity if MSU is suggestive of infection or patient is symptomatic. A postvoid residue can be assessed by measuring the volume by ultrasound or by direct measure with use of catheter. A bimanual exam is done to assess for  uterine size and presence of adnexal masses.. A rectal exam noting the sphincter tone and perineal sensation should be done to assess for posterior vaginal wall prolapse, constipation investigation and rectal incontinence.

Patient should be asked to keep a bladder diary noting frequency of voids, the volume voided, episodes of incontinence and any triggering factors. This should be noted over three days and including work and leisure activities.It is an objective to way to assess the symptoms and detect fluid intake and habits of patient.

Urodynamic studies are not requested upon initial assessment of patient with clinically detected case of  stress incontinence before conservative treatment as it will not change the outcome. It is only undertaken before surgical management if the symptoms are suggestive of a mixed cause of incontinence, if there is previous incontinence surgery and if there is symptoms of voiding dysfunction

(b) She has urodynamic stress incontinence and is considering surgical treatment. How would you counsel her about the role of tension-free vaginal tape in treating her symptoms? [8 marks]

TVT is minimally invasive procedure that consist of a macroporous mesh that is placed under midurethra and passed from bottom up behind the bladder, so as to increase the urethral resistance.  Whenever the patient coughs or strains, the mesh will act as a shelf supporting the bladder neck. It is done under local or regional analgesia.The success rate is around 85-90% at 5 years postop. The objective cure rate at 3 years is 86%.The potential risks are bleeding intraop, bladder perforation 9%, that’s  why a cystoscopy should be done after inserting the mesh to check for bladder perforation which occurs while passing upwards the mesh guides posterior to the bladder. The patient should also be counselled about voiding dysfunction as they occur in 4% and extremely disturbing to patient. De Novo detrusor overactivity can occur in around 15% of cases. the MHRA reported a 9% incidence of sexual problems present at least 6 months postop. The mesh will be incorporated within the patient tissues by growth of tissues through their pores. Mesh erosion in which the mesh is seen extruding through the vaginal mucosa is seen in 1-5% and can occur years after surgery. Treatment in this case is excision of the mesh. In there is recurrence of incontinence (6%of cases) patient can undergo another continence surgery using a different approach e.g transobturator tape , but should be informed that rate of success is slightly less than first time continence surgeries.

urinary incontinence Posted by Dr.Tamizharasi M.

a)                    Based on her history, symptom suggestive of stress urinary incontinence.  Urinary Incotinence is distressing and embarrassing condition for the woman.Her initial assessment includes detailed history  about duration of the problem, volume of loss ,number of leak per day is asked.Impact of her problem on quality of life is assessed using I-QOL questionnaires.Any associated symptoms like dysuria ,increased frequency of urination suggestive of UTI is asked for. Associated symtoms like  faecal urgency ,incontinence is asked for would suggest, this  problems may be birth related.Onset  of urinary  leakage following any particular event like childbirth, surgery like hysterectomy is asked for, because this may cause pelvic floor dysfunction. History of sexual dysfunction and her future child bearing wishes are assessed.History of recent weight gain, cough following chronic  smoking and alcohol intake are asked for because lifestyle modification would help the woman.Review her drug  history to look for drugs like ACE inhibitors as a cause for cough.
                       Examination is done to assess her BMI, BP,abdominal examination to look  for any abdominal or pelvic masses.Local examination of external genital to look for excoriation and inflammation might suggest severity of urinary leak. Examination done with full bladder to check for urinary leak on exertion.Speculum examination is done  to look foy anterior or posterior vaginal wall prolapse. Pelvic examination to look for size of uterus, and  to exclude adnexal masses. Digital examination of pelvic floor muscle is  done to assess contraction. Rectal examination is indicated if woman has symptoms like faecal urgency or incontinence to assess anal sphincter tone and integrity.
        Urine dipstick test to look for nitrites, leucocytes, hematuria, and  glucose. Presence of nitrites and leucocytes indicates urinary  infection, MSU  is sent for culture and analysis of antibiotic sensitivity . USG  to assess post void residual volume of urine is done in woman with recurrent UTI. Urodynamic investigation is not done before conservative management for urinary incontinence.
B)                     The reasons for her request for surgery before conservative management is gently explored and counselling done .Woman must be informed that TVT  is a minimally invasive surgery done through vagina with two small incision in the bikini line , using nonabsorbable synthetic tape which supports urethra and bladder neck and prevents urinary leak when  she  coughs or strain with success rate of 85% at the end of 5years. Woman must be informed that its a day case surgery done under local anaesthesia or general anaesthesia or through injection in your backbone. The tape used for surgery would not produce any allergic reaction or disturb  her sexual function  has to be explained to her.Her future child birth wishes are enquired and need for caesarean section   if she conceives in future  to preserve its function has to be explained to her.Post operatively she may have voiding dysfunction,  urinary leak preceded  by urgency  are explained. Risk of needle going through the bladder(8%) and bleeding during  surgery is explained and problems can be  managed using endoscope to visualise inner wall of bladder.woman must be informed that she may have bleeding for a week postoperatively and normal activities started after a week. Written patient information leaflet provided about surgery with support group organisation  web addesses  forany further query
 

Essay 276 Posted by khalid M.

A] Take a detail history  of duration of urinary leakage and associated symptoms such as dysuria , frequency, nocturia to see if it due to overactive bladder  . any history of voiding difficulties ,urinary dribbling , hesitancy and poor stream of flow of urine . any urinary tract infection symptoms such as frequency, dysuria, heamaturia . any history of incomplete emptying of bladder, bladder pain . past obstretic history such as  duration since last child birth , number of children , mode of delivery and any further fertility wishes . any history of previous similar complaints , any treatment done including medical or surgical treatment . ask her how is this effecting her quality of life . any history of previous medical disorders such as diabetes  and any previous surgeries done .  any history of ingestion of drugs for chronic  medical conditions and drugs such as diuretics  . any history of symptoms of prolapse such as chronic back ache, feeling of lump in her vagina , incomplete emptying of bowel and bladder. any history of chronic cough , constipation which may exacerbate her symptoms . any history of fecal incontinence . any history of excessive fluid intake including caffiene . ask her  about axess to the toilet. any history of recreational habits such as consumption of alcohol, smoking  and any recreation drugs .Examination -Temperature, pulse, BP, BMI .Per abdomen to palpate any Masses and palpable bladder . Speculam examination in left lateral position and maximum valsalval examination to check for uterovaginal prolapse and cystocele . Before taking up investigation ask the patient to maintain a three day dairy to recognise the symptoms . investigations such as blood for FBC, RFT , LFT . urine analysis for protein, ketones , sugar, leukocytes, nitrites. Demonstrate urinary incontinence by putting the patient in lithotomy position and  filling the bladder moderately and asking her  to cough . USG for any abdominal and pelvic masses and for residual urine . Multichannel audio and visual cystometry  is done only if there is  failed previous treatment, planning surgical treatment and to demonstrate detrossur overactivity .

B] Tell her that retropubic bottom up  TVT has success rate similar to burch colposuspension . 5 year success rate is about 85-90%. Explain the procedure  to the patients including there risks and benefits. Tell her that it is a day case procedure, done under local anaesthetia or regional anaesthetia . where the neck of the bladder  is lifted to increase the urethral resistance and correct USI , this also corrects cystocele . This procedure is quick, costly than open procedure, good success rate . this procedure is  prefered  for females who cannot with stand general anaesthetia  . This procedure will affect the patients sexual life for about 6 months , she will have pain and dysperunia   . But there is risk of infection, haemorrhage, mesh erosion and damage to bladder  .there is increase risk of urinary retention and voiding dysfunction after the procedure needing intermittent self catheterisation  for short time . there is risk of mesh migration where she may need further surgery to remove the mesh . long term data about mesh  migration is not known . Polypropylene macroporous mesh is used . Autologous slings such as rectus fascia can be used . other procedure such as Transobturator top down procedure can be done with synthetic sling  , it is successful but long term data is not known .  . There is increase rate of failure if the procedure is done  after a  previous failed  procedure . Provide information leaflet and contact details of support group and necessary web site detail and further appointment for more discussion if needed.

essay Incontinence Posted by sowba B.

The woman’s complaint suggests a stress incontinence, I will ask for the duration of her problem. Other urinary symptoms like urgency,urge incontinence,nocturia and frequency will point to a mixed incontinence.I will ask for history of hesitancy,dribbling,poor stream ,straining to void suggestive of Voiding Dysfunction.Symptoms of frequency,dysuria, hematuria point to an Urinary tract infection.History of mass descending per vaginum suggests a Prolapse.I will ask her which is her most troublesome symptom.Bowel symptoms like constipation may be a cause for stress.Incontinence to faeces ,flatus should also be asked.I will ask her obstetric history namely the number,type of deliveries,time of last delivery and any problems postpartum.Her future reproductive intentions must be noted.History of previous treatment ,any surgery for stress incontinence must be asked for as it will have a bearing on current treatment plan.I will ask about her pattern of fluid intake,caffeine,alcohol.A social history namely her working conditions,mobility,access to toilets and smoking should be gently enquired.I will check her BMI as obesity precipitates stress incontinence.Abdominopelvic examination to be done to look for palpable bladder  or a mass causing pelvic pressure.Perineal sensation and pelvic floor muscle tone to be checked digitally. I will examine for stress with a moderately full bladder. A urine dipstix has to be done to see for glucose,protein, blood ,nitrites and leucocytes ,the last two could suggest an infection.UTI is then confirmed with culture of midstream urine.An ultrasound to be done to check residual urine. Iwill also tell her to maintain a ‘BLADDER DIARY’ for 3 days covering her variations in day to day activities,where she notes her incontinence episodes.This will help in a better clinical diagnosis
                                I will sensitively explore the reasons why she wants surgery as a treatment.I will gently ask if she tried pelvic floor exercises ,if so how she did it and for how long as that is the recommended first line treatment .  The choice of surgery depends on if it is a primary surgery, presence of prolapse and her urodynamics report.I will involve her in decision making ,and go on to counsel her about TENSION FREE VAGINAL TAPE (TVT), a retropubic mid urethral tape which supports the proximal urethra and bladder neck,thereby preventing stress.  TVT is the best choice for her especially if her urodynamics suggest a low urethral pressure .I will explain that the procedure can be done as a day care under regional or local anaesthesia.A knitted prolene mesh is inserted through a small groin incision both sides,brought out through a vaginal incision just under the mid urethra and with time ,tissue fibrosis in and around the tape supports the urethra.I will tell her the success rates are 85-90% in the first year and remains 80% even at 5 years.The procedure is safe in skilled hands with a small risk of bleeding and 8% risk of bladder injury. Incidence of short term voiding dysfunction is 4%,Denovo detrusor instability in 3 to 15%  .At 6 months, there is almost no pain,sexual dysfunction in 9 -10%, tape erosion in 1% ansd need for repeat surgery in 1 to 2%. I will also tell about TVT-SECURE a single incision method with similar success but erosion is higher8%. I will provide her Information Leaflets and details of support group websites like www.continence foundation.org.uk,www.bupa.org.

 

ans incontinence Posted by Mukta P.

I'd like to ask her in detail regarding her symptoms like how much is the urine leakage, does it occur only on cough or any other activity like laughing, lifting heavy weights as i may need to do these for eliciting her symptoms on examination. i'd  ask about other symptoms like frequency, urgency, urge incontinence, nocturia as this may suggest associated detrusor instability . i'd like to know about voiding problems like hesitancy, poor flow as this will change my counselling and treatment.i'd ask how much is this affecting her life, and any previous treatment that she has taken for it,like pelvic floor exercises, drugs.i'd like to know if she has dysuria as that'll suggest urine infection and will need investigation and treatment prior to other treatments.i'd ask regarding any symptoms of prolapse as that increases the incidence of urine incontinence and will affect management decision. i'd also ask regarding history of chronic cough or constipation , as these may be the cause of increase in intraabdominal pressure and predispose to incontinence. i'll enquire about her lifestyle and drinking habits,whether she has maintained a bladder diary, as that'll help me see fluid  intake and episodes of incontinence. i'd ask about her menstrual and obstetric history to know from obstetric history any predisposing factors for prolapse,and urine incontinence.i'll ask about drug history like thiazides/diuretics as that may cause her to have frequent micturition,or overflow incontinence.i'll ask her about any history of fibroids as that may cause pressure symptoms and predispose to urine incontinence on coughing.

on examination, i'll check her BMI, abdominal examination to look for obvious pelvic mass. speculum examination (with full bladder) i'll ask her to cough and try eliciting stress incontinence. look for prolapse/cystocele.i'll look for pelvic floor muscle strength.

i'll do a urine dip for UTI.  i'll counsel her that the first line treatment is pelvic floor exercises, if not done already, as that has been proven to reduce the stress incontinence.

b)- i'll discuss about tension free vaginal tape, that it is a tape that gives support to the weak muscles under the urethra and will treat her stress incontinence.it causes less bleeding, no scar in abdomen( done vaginally),early recovery, shorter hospital stay, less morbidity,quicker return to active life than traditional colposuspension procedures. there are few risks associated like risk of bladder perforation, pelvic pain. Voiding dysfunction if present before, gets worsened(hence should be ruled out before procedure). there is a risk of mesh erosion, and mesh migration. I'll provide her with written information to go through. i'll give her details about support groups. 

 

Mukta Posted by Farrukh G.

 

I'd like to ask her in detail regarding her symptoms like how much is the urine leakage, does it occur only on cough or any other activity like laughing, lifting heavy weights as i may need to do these for eliciting her symptoms on examination is leakage on coughing not enough? Are you going to make her laugh / lift weights during examination? . i'd  ask about other symptoms like frequency, urgency, urge incontinence, nocturia as this may suggest associated detrusor instability (1). i'd like to know about voiding problems (1) like hesitancy, poor flow as this will change my counselling and treatment.i'd ask how much is this affecting her life (1), and any previous treatment that she has taken for it,like pelvic floor exercises, drugs.i'd like to know if she has dysuria as that'll suggest urine infection and will need investigation and treatment prior to other treatments.i'd ask regarding any symptoms of prolapse which symptoms? as that increases the incidence of urine incontinence and will affect management decision. i'd also ask regarding history of chronic cough or constipation , as these may be the cause of increase in intraabdominal pressure and predispose to incontinence. i'll enquire about her lifestyle and drinking habits (1),whether she has maintained a bladder diary, as that'll help me see fluid  intake and episodes of incontinence. i'd ask about her menstrual and obstetric history to know from obstetric history any predisposing factors for prolapse such as??,and urine incontinence.i'll ask about drug history like thiazides/diuretics ? healthy 37 year old as that may cause her to have frequent micturition,or overflow incontinence.i'll ask her about any history of fibroids as that may cause pressure symptoms and predispose to urine incontinence on coughing.

on examination, i'll check her BMI, abdominal examination to look for obvious pelvic mass (1). speculum examination (with full bladder) i'll ask her to cough and try eliciting stress incontinence. look for prolapse/cystocele.i'll look for pelvic floor muscle strength. ? VE

i'll do a urine dip for UTI how do you diagnose UTI?.  i'll counsel not asked about counseling her that the first line treatment is pelvic floor exercises, if not done already, as that has been proven to reduce the stress incontinence.

b)- i'll discuss about tension free vaginal tape, that it is a tape that gives support to the weak muscles under the urethra which muscle is this? and will treat her stress incontinence.it causes less bleeding, no scar in abdomen she will be surprised when she finds 2 scars ( done vaginally),early recovery, shorter hospital stay, less morbidity,quicker return to active life than traditional colposuspension procedures. there are few risks associated like risk of bladder perforation how high?, pelvic pain. Voiding dysfunction if present before, gets worsened(hence should be ruled out before procedure). there is a risk of mesh erosion how high?, and mesh migration what is the difference?. I'll provide her with written information (1) to go through. i'll give her details about support groups.  See answers above and read MHRA report in notes

Saq 276 answer -incontinence Posted by Liza S.

 

SAQ 276 – incontinence
A)Enquire about duration, severity of symptoms, and impact on quality of life .I will ask the obstetric history including mode of delivery and any history of perineal injury and whether or not she has completed her family, also ask the most recent delivery as stress incontinence is common post-partum and improves spontaneously in most women. I will also ask the future childbearing wishes as they have impact on surgical treatment. Enquire about her bowel symptoms like constipation and faecal/flatus incontinence as women may not volunteer this symptoms, as they may predispose urinary incontinence and adversely affects the outcome of any continence surgery. I will enquire her habit of fluid intake, type and amount of fluid she is taking, like if taking too much coffee which may be over flow incontinence. Enquire about her sexual function did she has any coital incontinence. I will ask the surgical history that if she any previous surgery for urinary incontinence which can complicate the treatment and the diagnosis more complicated. Enquire about any symptoms of U.V prolapse like something coming down or out of vagina, a un- comfortable feeling of fullness, difficulty having sex.
Examination is carried out to guide the diagnosis and management of incontinence and identification of any underlying pathological condition. Examine the weight and BMI as obesity is one the risk factor for incontinence; examine the chest for any pathology leading to chronic cough which may exaggerate stress incontinence. Examine the abdomen which can detect a significantly enlarged bladder or palpable pelvic mass, a palpable bladder may indicate the presence of chronic urinary retention. Ammoniacal dermatitis may be present in severe cases. Speculum examination –? Prolapse, mobility of bladder neck, may elicit urinary leakage on coughing; absence does not exclude stress incontinence. I will assess pelvic floor tone and perineal sensation to touch and pin-prick .Vaginal examination can assess POP and identify infection and excoriation. Uterine and ovarian enlargement may be determined by bimanual examination. Rectal examination if clinically indicated by a history of constipation, prolapse or faecal incontinence if present, used to further evaluate posterior wall prolapse. Investigation will include –MSU, dipstick and culture to exclude UTI and glycosuria. Obtain a urinary diary by encouraging the women to complete in a minimum of 3 days of the daily covering variation in her  used activities such as both working and leisure days it will record the leakage episodes, fluid intake and pad changes, and it  will give an indication of the severity of wetness.  Pelvic ultrasound can be requested if clinical pelvic assessment inadequate. Urodynamic studies are not necessary in the initial assessment   if this woman presented  first time with SUI and no other symptoms unless surgery is contemplated.
B)This woman has to know that if she is considering the surgical treatment for her USI, TVT is the operation of choice for a primary procedure for SUI. This procedure will support the mid part of the urethra and it will increase the urethral pressure to prevent urine leakage .TVT has an advantage that it can be done as a day case procedure which can be performed under Local anaesthesia. Success rate 85-90 %. It is a minimally invasive procedure with low intra and post-operative morbidity, quicker recovery and equivalent long term success rates. The main complication is the bladder injury (0.9-2.5%), however, in most cases it has no long term effects if recognized at the time of surgery and corrected. Bleeding complication rate is 0.9-2.35% also there. Voiding dysfunction (7.6%) and UTI (4.1%) are also the disadvantage of this procedure. Bowel injury rate are rare but potentially a fatal complication of TVT. Mash erosion is a long term complication of this procedure. Sexual dysfunction is also noted after 6 month of surgery .Long term result confirms durability of success rates. Provide the information leaflet to the patient.