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MRCOG PART 2 SBAs and EMQs

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EMQ1480
SBA2073
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GSI

GSI Posted by Sunitha P.
A 57-year-old woman c/of urinary leakage has GSI. Critically appraise the surgical treatment options.


GSI is the involuntary loss of urine on straining like coughing, laughing in the absence of detrussor instability. It is due to the loss of vesicourethral angle resulting in increase in the intra abdominal pressure, which exceeds the urethral closure pressure.
Age by itself due to the loss of estrogen, parity when increases causing loss of the vesicourethral angle mode of delivery leading to pudental nerve denervation are etiological factors. Contributing to is obesity, constipation, chronic cough, and any intraabdominal mass altering the pubovesical angle.
Before any surgical treatment is planned it is necessary to rule out any detrusssor instability. If not voiding problems are worsened after correction. This can be done by uro dynamic studies, which measure the resting detrussor pressure, flow rate, residual urine volume and pressure on voiding. Urine culture of the mid stream sample to rule out any urinary infection. A 3-day assessment of urine volume and frequency using frequency volume chart.
The management begins with advice regarding life style modifications fluid intake weight reduction avoiding constipation and treatment of any medical conditions like diabetes mellitus. The role of kigles exercise, 2 minutes twice daily has 60%short term cure rate.biofeed back, electrical stimulation, acupuncture and inter ferential therapy are being evaluated. The role of estrogen is not being proved useful. Surgical treatment potions depends on association with prolapse, previous surgery technical expertise and patient preference.colposuspension –Brusch is elevating the pubocervical fascia to the ipsilateral ileo pectineal ligament. It has 80%success rate at 1year and 77%success rate at 5 years. The complications like detrussor instablity14% voiding problem10%rectocele and enterocele15% may be present. The MMK is elevating the pubo cervical fascia to the pubic bone.the complications like ostitis pubis is 2.5%it is seldom these days due to poor long-term successes rates although short-term successes rate is around 85%. Laproscopic suspension is equally effective but expertise and suture material is important. Slings using mersilene tape, rectus sheath, fascia lata are having successes rate of 85% in 1 year. It is effective especially in intrinsic sphincter defects. Complications include bleeding, perforation and erosions.it is not recommended due to long-term failure and complications. N eedle suspension procedures like staey and pereyra have short and long term complications and are not used. I njections using macroplastique, collagen for intrinsic sphincter defects and recurrence after surgery are used. It is an out patient procedure under local with fewer complications and good short-term effects