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MRCOG PART 2 SBAs and EMQs

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EMQ	1502
SBA	2115

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ESSAY 157 - INCONTINENCE

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		Posted by Nitin P. Sat Jul 16, 2005 06:26 am
a)Urinary incontinence may cause significant loss of quality of life and psychological distress. Stress urinary incontinence is the involuntary passing of urine caused by raised intra abdominal pressure. It is important to note on history the degree of symptoms and effect on quality of life. Causes of pelvic muscle weakness such as history of surgery, multiple sclerosis, spinal trauma must be explored. Chronic constipation and cough may also lead to pelvic muscle weakness. Her obstetric history would also provide a clue regards the cause especially if she has had traumatic deliveries. If there is a history of a chronic cough, it is important to have a respiratory system examination. Similarly, a neurological examination to rule out any neuropathy is important. The abdomen should be checked to confirm the absence of any pelvic tumour. On local examination, the perineal muscle tone should be observed. There may be associated cystocele evident on examination. Scarring from previous surgery may also be evident. She also needs to be examined in the standing position with a full bladder to demonstrate stress incontinence. It is important to confirm the absence of urge incontinence, as surgery in the presence of urge incontinence may give rise to new symptoms post operative. An MSSU is essential to rule out any urinary infection. A bladder diary would help to rule out urge incontinence. An ultrasound scan will help to rule out a space occupying lesion in the pelvis. Although the history strongly suggests stress incontinence, it is important to rule out urge incontince, a small bladder and also overflow incontinenc and hence a urodynamic study is essential. In case, urge incontinence or a small bladder is suspected on the other investigations a cystoscopy may be needed. b)Non surgical management of stress incontinence is not only the first line of treatment but needs to be continued even if surgery is done. Regularisation of fluid intake, with keeping low volumes before travel outside the house, is a simple but effective advice. Smoking may be a cause of the cough, and hence should be stopped. In case, any specific cause for the cough has been detected this should be appropriately treated. Similarly constipation should be treated. Referral to a dedicated Physiotherapist is known to have beneficial effects in upto 60% of individuals. However, a strong degree of motivation, follow up and group therapy also helps. The physiotherapy may be in the form of pelvic floor exercises and aided with Bio feed back or electral stimulation or graded vaginal cones. Urinary incontinence pads may be used as a temporary relief till the effects of physiotherapy are obvious, as these may take upto 6 weeks. Urethral plugs is another option but the discomfort limits its use. Duloxetine is an noradrenergic and serotonergic drug which leads to increased tone at the sphincter. This may be used along with the other measures. The main side effects are palpitations, insomnia and headaches. A multi disciplinary approach involving the physiotherapist, incontinence nurse and regular follow up is essential for the success of the non surgical techniques.
		Posted by salma S. Sat Jul 16, 2005 06:36 am
Initial assessment will include history and examination. Although she does not complain of any other symptoms nature of incontinence is confirmed by excluding certain conditions like urge, mixed, continuous or dribbling and incontinence during intercourse. This is done by asking other urinary symptoms like frequency of micturition, timing whether it occurs during day or night time (nocturia), urgency, dysuria, haematuria; hesitancy, poor stream, double voiding and straining to void (voiding difficulties); nocturnal enuresis and bladder pain. She should be enquired about incontinence of faeces and flatus. Any symptoms of prolapse like something coming out of vagina, dragging sensation, backache and vaginal discharge. She should be asked about functional impact of these symptoms that is effect on work life, sports, personal hygiene and if she needs to wear a pad for instance and duration and progression of symptoms. An important question is to ask about fluid intake and in particular caffeine containing drinks. As this woman is a mother of 3 her Obstetric history is especially important. She should be asked about history of any prolonged labour and any evidence of pelvic floor injury such as third degree tears. Surgical and gynaecological history is also important any history of pelvic and incontinence surgery, results of previous treatments for incontinence and pelvic irradiation. She should be asked about Medical history and drug therapy for example diabetes mellitus, diabetes insipidus, cardiac failure; chronic cough and constipation, neurological disease and diuretic therapy. It is also important to ask about reproductive intentions as this woman is of premenopausal age. Examination will include General examination including fitness for surgery, mobility and dexterity, abdominal examination to exclude abdomino-pelvic mass and palpable bladder. Pelvic examination is done to check for any vaginal discharge as this may be mistaken for incontinence. Stress incontinence is demonstrated preferably with moderately full bladder. Examination for uterovaginal prolapse is done with the help of sims speculum. Bimanual examination may be done for pelvic masses and mobility of the anterior vaginal wall. In case a neurological disease is suspected Neurological examination is done. Investigations include MSU and dipstix for blood, protein, leukocytes, nitrite and glucose. Patient is asked to keep a urinary diary with Frequency-volume charts. Multi-channel urodynamics will help in determining the type of incontinence although there is controversy regarding their use. Ultrasound assessment of bladder volume may be required. If fistula suspected then EUA, cysto-urethroscopy and dye test will be done to establish the diagnosis. Non-Surgical treatment options starts with general measures like treatment of chronic cough, chest conditions, weight reduction and stopping smoking may produce symptomatic improvement. Up to 50% of women will obtain sufficient benefit from non-surgical treatments to avoid surgery. Pelvic floor muscle exercises are shown to significantly reduce stress incontinence and are more effective than electrical stimulation of the pelvic floor or vaginal cones. These should be undertaken for 15-20 weeks. The addition of bio-feedback does not appear to improve outcome. Physiotherapy is particularly useful as a first-line measure in women unsuitable for surgery or reluctant to undergo surgery, mild stress incontinence, concomitant detrusor instability or voiding dysfunction and women who have not completed their family. About 27 - 67% of women are cured or improved. It is suggested that all women contemplating surgery should be offered a trial of physiotherapy. Medications that are used include duloxetine which is a combined serotonin and noradrenaline re-uptake inhibitor. Meta-analysis of placebo controlled trials show that duloxetine resulted in a significant reduction in incontinence episodes per week and A significant reduction in social embarrassment and psychological impact of incontinence and a significant improvement in quality of life. Regarding Oestrogen replacement although uncontrolled trials have reported a subjective improvement in symptoms of incontinence, randomised trials have shown that oestrogen replacement does NOT improve objective measures of incontinence. Alpha adrenergic agonists Phenylpropanolamine is not significantly different when compared to pelvic floor muscle exercises with 84% and 77% improvement respectively. Mechanical devices like Bladder neck support prosthesis are available in 24 sizes. These are not assessed in randomised trials but observational studies report up to 87.5% objective success rate at 12 months and improved quality of life scores. Complications include cystitis (15.4%), increased vaginal discharge (vaginal oestrogen cream used) and vaginal abrasions. Continence guard, urethral plugs are other available devices
		Posted by uma M. Sat Jul 16, 2005 06:59 am
Urinary incontinence is a physical ,social problem also associated with psychological morbidity.To over come this management should aim to provide symptomatic relief. Initial evaluation of this woman starts with detailed history.Enquire about her obstetric history -any traumatic vaginal deliveries, instrumental deliveries which can cause this problem, last child birth to know if she is postpartum and any future intention of having childbearing they have impact on surgical treatment.Enquire about duration ,severity of symptoms, impact on quality of life.Note any history of neurological problems.Ask if she has any faecal(anal) incontinence as women may not come out on her own. Note her social habits like drinking alcohol ,caffeine , also her fluid habits. Enquire if any treatment was taken for the incontinence -surgery/nonsurgical. Examine her wt and BMI,chest for any pathology leading to chronic cough which may exaggerate stress incontinence.Abdominal examination for any palpable masses, full bladder from chronic retention is done. on Vaginal examination note if any cystocele ,prolapse, any pelvic masses. Demonstrate SUI with full bladder, in lithitomy position.At all times it may not be possible to demonstrate, at times may need to change the position of the patient(standing,squatting).Pelvic floor muscle tone is checked.Peri anal skin sensitivity,anal reflex tested for evidence of any neurological impairment.Anal sphincter tone noted. Mid stream urine is tested for any infection as UTI can cause this problem. Ask her to maintain urinary dairy and monitor fluid intake.This will guide regarding severity of symptom,also help in counselling her,and later guide regarding response to treatment which can be explained to her. Genuine SUI is most likely diagnosis as she has no other symptoms, however it should be noted that DI , mixed incontinence can present similarly, and can only be diagnosed accurately by urodynamic investigations.These are not indicated at this stage,as nonsurgical options can be tried Non surgical treatment options include treating any UTI, precipitating causes like cough,constipation, if obese -wt. reduction,life style alteration like avoid excessive caffeine,alcohol, stop smoking .These produse symptomatic improvement in upto 40% Pelvic floor exercises are usefull especially in this age group women, with symptomatic improvement in 30-65% of them. No advantage of using electrical stimulation, vaginal cones or biofeed back over and above pelvic floor exercises.Women should be taught which muscles to contract, supervised by physioterapist,incontinence nurse.But this is assosiated with high relapse rate upon discontinuation. Mechanical devises like bladder neck prosthesis has shown to improve QOL in observational studies,in 80% of women.But this is assosiated with increased UTI, vaginal discharge, vaginal erosion.Women with infrequent symptoms are better candidates for mechanical devises especially for devices like urethral plugs which occlude the urethra.She can use when she need\'s to occlude. She can use continence pads to protect her clothing . Drugs have only small role for SUI.As she is 35 yr old estrogen deficiency is unlikely.No evidence that estogen improves symptoms.Phenylpropanolamine an alpha adrenergic agonist has been shown to improve symptoms in upto 75% of women.Duoloxetine is been used for stress symptoms. Evidence is very recent, no long term data available. it increases urethral sphincter tone by inhibiting reuptake of serotonin and noradrenaline.Dose 40 mg bd. It\'s use have showed significant reduction in incontinence episodes, improve QOL, reduction of social embarrasment and psychological impact. Conservative management has advantage that it avoids surgery and risks assosiated with it,is less expensive. If symptoms fail to resolve with nonsurgical treatment she should be sbjected for urodynamic evaluation prior to surgery. Surgery is gold standard treatment for G-SUI. If DI is identified on testing manage her with anti cholinergic drugs and bladder-retraining. Mixed incontinence - DI should be treated first.
		Posted by jyoti D. Sat Jul 16, 2005 11:33 am
The initial assesment includes relevant history taking,investigations.Duration of the symptoms,whether associated with sneezing ,laughing,execises,cycling should be asked .History of constipation, dragging sensation to rule out prolapse should be enquired.Obstetric history including mode of deliveries if vaginal the weight of babies history of any traumatic or prolonged labour should be enquired.Age of last child birth to see if she is immediate post delivery and breast feeding.Medical history of diabetes,hypertention,neurological(multiple sclerosis) disorders,asthama should be asked.Any previous surgeries for prolapse or urinary symptoms.Personal history of smoking and alchol.If using any diuretics for hypertension or cardiac problems should be asked. Check her body mass index. examine after verbal consent abdominally to rule out any palpable pelvic mass.vulva vagina for excoriation and any demonstrable urinary leakage,rectocele ,cystocele,uterovaginal prolapse and check for uretheral mobility.Do relevant neurological examination.Investigations include MSU to rule out urinary tract infections,random blood sugar for diabetes.Ultrasound to rule out any pelvic pathology.Urodynamic assesment as stress incontinence is a urodynamic diagnosis. Management depends if stress incontinence alone then pelvic floor exercises remains first line of treatment with 60% succes rate. general measures like treat cough,diabetes,constipation,weigth reduction,stop smoking,alcohol alter medications like diuretics. Maintain frequency volume chart.Use of continence pads. electrical nerve stimulation for pudendal dnervation mmay be helpful.Vaginal cones of increasing sizes may be helpful.Intravaginal mechnical devices are helpful but poor patient complaince.urethral plugs may be used. duloxetine a newer selective serotonine and nonadrenaline reuptake inhibitors is shown to improve the quality of life by decreasing the continence rates.rule out pregnency ,lactation and liver problems before starting.Side effects include nausea,headche,dry mouth. If mixed incontinence first treat detrusor instablity the general measures will help improve detrusor instability as well. pschological support and reassurance is required as part of management.Provide the women with leaflets and arrange for follow up appointment.
		Posted by Farzana N. Sat Jul 16, 2005 09:45 pm
The most probable diagnosis in this case is genuine stress incontinence. Initial evaluation of this woman would include taking detailed history including obstetric history, performing clinical examination and investigations. History of onset, duration, severity, and impact of symptoms on her social life should be taken, e.g. daily work, sexual life, personal hygiene (whether she needs to wear pads) .H/o fecal or anal incontinence is also taken as the woman may not volunteer this herself H/o fluid intake ,to rule out excessive fluid intake . Obstetric history is taken about any recent deliveries or difficult traumatic instrumental deliveries, involving third or fourth degree perineal tear. Her desire of future pregnancies would influence the management, if surgery were contemplated. Examination would include taking BMI?Chest examination for any respiratory illnesses, which would precipitate stress incontinence. Abdominal exam for any palpable abdominopelvic masses. Pelvic exam done to look for pelvic masses, which may be asymptomatic but may precipitate or exacerbate incontinence. Presense of cystocele may be a cause of incontinence. Assessment of pelvic floor muscles tone and perineal muscles to pin prick is done. Pt should be placed in lithotomy position and encouraged to cough with a full bladder to demonstrate stress incontinence. Investigation would include sending MSU for analysis to exclude UTI.Maintain fluid intake output chart for one week. B) There are several options for conservative, non- surgical treatment. The advantages are, the morbidity associated with surgical treatment can be avoided and also high satisfaction rate .The modification of fluid intake often reduces the symptoms of incontinence and monitored by keeping a fluid intake out chart. Treatment of chronic cough and constipation is helpful in controlling the symptoms. Symptoms of SUI may overlap with DI or mixed incontinence. Bladders training with voiding on schedule and relaxation techniques to suppress urge incontinence are taught. Physiotherapy in the form of pelvic floor exercises to strengthen pelvic floor muscles plays a major role in conservative management. It can give up to 60% improvement on 5yrs follow up. It should be taken wit5h the help of incontinence physiotherapist. But there is a high relapse rate once discontinued. Vaginal cones in increasing weights can be used as adjuncts to pelvic floor exercises. They can be retained in vagina by both active and contraction of pelvic floor muscles. Electrical stimulation of pudendal nerve is used to augment urethral sphinteric function and inhibit bladder contractility. Estrogens have not been shown to have beneficial effects on symptoms of stress incontinence. Alphaadrenergic agonists, e.g phenylpropanolamine is as effective as physiotherapy but their cardiovascular effects limit thier use. Mechanical devices, such as intravaginal continence guards to elevate bladder neck can be used if there are specific precipitating events.
		Posted by Sreekala S. Sun Jul 17, 2005 05:13 am
Urinary leakage on coughing is suggestive of Stress urinary incontinence. Initial assessment should include a detailed history, physical examination and some investigations to plan the best possible treatment for her. History should include onset, duration, amount leaking, whether she feels bladder fullness, symptoms of urgency, Obstetric history to know if she had prolonged labours or instrumental deliveries, drug history including any intake of diuretics, apha blockers, surgeries like hysterectomy, abdominal surgeries and any desire for future pregnancy should be noted. History of chronic straining with constipation, smoking, chronic lung diseases and lifting heavy weights should be enquired. Physical examination should include recording BMI, abdominal swellings, divarication of recti which may suggest increased abdominal pressure. she should be examined with full bladder to evaluate for incontinence and examine for any uterovaginal prolapse or cystocele. Strength of the pelvic muscle should also be evaluated. 1 hour pad test is a simple and inexpensive test by which loss of urine can be documented if incontinence could not be demonstrated while examining. A midstream urine specimen should be sent for microscopy and culture to detect urinary tract infection. A dairy of bladder function and fluid intake should be noted. Urodynamic studies should be done to confirm the diagnosis. Non surgical options: Non surgical options are simple, non invasive and less expensive. But, they do not give a permanent cure. A trial of conservative methods should be tried in all cases of stress incontinence before opting for the surgical methods. It is indicated when further child bearing is desirable or if the patient is unfit for surgery or prior to surgery when the patient is on a long waiting list. The response to non surgical methods is dependent on patient compliance and therefore needs patient motivation. Any local skin infections and irritation in the genital region from chronic urine contact should be treated. Cough control is important especially by treating an underlying pulmonary condition and cessation of smoking if she smokes. Measures to loose weight should be considered especially if obese. Lifting of heavy weights should be reduced and chronic straining with constipation avoided. Reducing fluid intake especially for women who drink an excessive amount of fluid is advisable. Modifying voiding habits by regulary emptying bladder may eliminate leakage that occurs mainly with very full bladder. Minimizing caffeine intake is also helpful, as caffeine increases urine production. Physiotherapist should be involved in teaching the pelvic floor exercises(Kegel\'s exercises) to strengthen the pelvic floor muscles. Patient education is vital as the correct muscles should be used during exercises. She should contract the pelvic floor muscles for 10 seconds and relax for 10 seconds and do them 10-15 times twice or thrice daily. Biofeed back training increases the efficacy of pelvic floor muscles as the patient can know if she is using the correct muscles and appropriate amount of contraction. Contracting the pelvic floor muscles using weighted vaginal cones (20-90g) startiing with the ligtest cone in vagina for 15minutes twice daily to prevent the cone from falling out of her vagina is thougt to have 70% objective cure rates. Patients unable to perform Pelvic floor exercises can use electrical stimulation of pudendal nerve. Extra corporeal magnetic innervation (EXMI) is a non invasive alternative in which the patient sits fully clothed in a chair for 20 minutes tiwce weekly for 2 months. Urethral and vaginal devices can also be used. The urethral devices are placed either within the urethra or over the external meatus. Main drawback with these are patient discomfort and risk of infection. Vaginal devices like pessaries, tampons and bladder neck support prostheses can also be used but they need to be removed periodically and cleaned and need follow up to check for irriation or erosion of vaginal walls. Periurethral Injections with bulking agents like collagen can be used, but multiple injections may be needed. Pharmacological agents mainly act by increasing the urethral resistance. Alpha agonists like ephedrine, pseudoephedrine, norephedrine can be used if medcially not contraindicated as they may aggravate HTN, hyperthyroidism, arrthmias, angina. Imipramine is a tricyclic antidepressant with alpha agonist and anticholinergic properties. It should be used with caution in patients with narrow angle glaucoma, HTN, angina and arrhthmias. Estrogen(oral/vaginal) is known to be beneficial in stress incontinence but the patient must be aware of breast/endometrial cancer, venous thrombosis, liver disease and gall stones. concomitant progestogens need to be given if the uterus is present. Duloxetine is a potent and balanced dual reuptake inhibitor of norepinephrine and 5 HT. But, it can cause nausea, fatigue, constipation, headache, dizziness. It should be remembered that for non surgical methods to be effective patient motivation and compliance is essential.
		Posted by Sreekala S. Sun Jul 17, 2005 05:26 am
Urinary leakage on coughing is suggestive of Stress urinary incontinence. Initial assessment should include a detailed history, physical examination and some investigations to plan the best possible treatment for her. History should include onset, duration, amount leaking, whether she feels bladder fullness, symptoms of urgency, Obstetric history to know if she had prolonged labours or instrumental deliveries, drug history including any intake of diuretics, apha blockers, surgeries like hysterectomy, abdominal surgeries and any desire for future pregnancy should be noted. History of chronic straining with constipation, smoking, chronic lung diseases and lifting heavy weights should be enquired. Physical examination should include recording BMI, abdominal swellings, divarication of recti which may suggest increased abdominal pressure. she should be examined with full bladder to evaluate for incontinence and examine for any uterovaginal prolapse or cystocele. Strength of the pelvic muscle should also be evaluated. 1 hour pad test is a simple and inexpensive test by which loss of urine can be documented if incontinence could not be demonstrated while examining. A midstream urine specimen should be sent for microscopy and culture to detect urinary tract infection. A dairy of bladder function and fluid intake should be noted. Urodynamic studies should be done to confirm the diagnosis. Non surgical options: Non surgical options are simple, non invasive and less expensive. But, they do not give a permanent cure. A trial of conservative methods should be tried in all cases of stress incontinence before opting for the surgical methods. It is indicated when further child bearing is desirable or if the patient is unfit for surgery or prior to surgery when the patient is on a long waiting list. The response to non surgical methods is dependent on patient compliance and therefore needs patient motivation. Any local skin infections and irritation in the genital region from chronic urine contact should be treated. Cough control is important especially by treating an underlying pulmonary condition and cessation of smoking if she smokes. Measures to loose weight should be considered especially if obese. Lifting of heavy weights should be reduced and chronic straining with constipation avoided. Reducing fluid intake especially for women who drink an excessive amount of fluid is advisable. Modifying voiding habits by regulary emptying bladder may eliminate leakage that occurs mainly with very full bladder. Minimizing caffeine intake is also helpful, as caffeine increases urine production. Physiotherapist should be involved in teaching the pelvic floor exercises(Kegel\'s exercises) to strengthen the pelvic floor muscles. Patient education is vital as the correct muscles should be used during exercises. She should contract the pelvic floor muscles for 10 seconds and relax for 10 seconds and do them 10-15 times twice or thrice daily. Biofeed back training increases the efficacy of pelvic floor muscles as the patient can know if she is using the correct muscles and appropriate amount of contraction. Contracting the pelvic floor muscles using weighted vaginal cones (20-90g) startiing with the ligtest cone in vagina for 15minutes twice daily to prevent the cone from falling out of her vagina is thougt to have 70% objective cure rates. Patients unable to perform Pelvic floor exercises can use electrical stimulation of pudendal nerve. Extra corporeal magnetic innervation (EXMI) is a non invasive alternative in which the patient sits fully clothed in a chair for 20 minutes tiwce weekly for 2 months. Urethral and vaginal devices can also be used. The urethral devices are placed either within the urethra or over the external meatus. Main drawback with these are patient discomfort and risk of infection. Vaginal devices like pessaries, tampons and bladder neck support prostheses can also be used but they need to be removed periodically and cleaned and need follow up to check for irriation or erosion of vaginal walls. Periurethral Injections with bulking agents like collagen can be used, but multiple injections may be needed. Pharmacological agents mainly act by increasing the urethral resistance. Alpha agonists like ephedrine, pseudoephedrine, norephedrine can be used if medcially not contraindicated as they may aggravate HTN, hyperthyroidism, arrthmias, angina. Imipramine is a tricyclic antidepressant with alpha agonist and anticholinergic properties. It should be used with caution in patients with narrow angle glaucoma, HTN, angina and arrhthmias. Estrogen(oral/vaginal) is known to be beneficial in stress incontinence but the patient must be aware of breast/endometrial cancer, venous thrombosis, liver disease and gall stones. concomitant progestogens need to be given if the uterus is present. Duloxetine is a potent and balanced dual reuptake inhibitor of norepinephrine and 5 HT. But, it can cause nausea, fatigue, constipation, headache, dizziness. It should be remembered that for non surgical methods to be effective patient motivation and compliance is essential.
		Posted by Mangala sundari R. Mon Jul 18, 2005 02:37 am
This patient most probably has genuine stress incontinence.This condition is distressing socially, sexually and for personal hygiene This affects 1 in 10 women.. History is taken regarding severity , duration and the amount of leakage whether she needs to wear a pad or adult pamper. This severity will guide the physician the extensive investigations she needs to undergo. Her obstetric history is taken regarding any birthing injuries, or perineal trauma undergone surgery ,. Her personal history of smoking , alcohol drinks and chronic constipation? Her medication history which includes any medicines for renal or cardiac conditions necessitating diuretics,h/o diabetes mellitus, any HRT after premature menopause or surgical menopause, any descent of genital organs or surgery for prolapse,and any previous surgery for incontinenece and present medications if any for the same complaint? Many patients with stress incontinence have associated detrusor instability or urge incontinence or overflow incontinence or dribbling or a sensory urgeincontinenxce. This patient has only stress incontinence which is due to bladder neck dispalacement or due to intrinsic sphincter deficiency. She will be expalained with diagrams the leakage of urine is due to intravesical pressure exceeding the intraurethral pressure (in the absence of detrusor acivity ), when the intra abdominal pressure goes up like in her case coughing or sneezing.This may probably be due to child birth and relaxation of pelvic support and aging with reduction of connective tissue support..This is not a life threatening situation and needs motivation, exercises and when failed and in severe cases need surgical correction. Examination of abdomen to rule out any pelviabdominal masses, or ascites, .Gynaecological examination .any excoriation of the vulva due to chronic leakage of urine , any genital prolapse, cystocele,or impacted stools,.look for urine leakge on coughing either in lithotomy position or in standing position if bladder is moderately full .Bimnual examination to look for any urehrocele,anterior vaginal wall and the suburethral region for the pliability and mobility of the urethra.. If she had hysterectomy, the vault is examined for any prolapse or cystocele oe rectocele and note the hypoestrogenic vaginal mucosa. Investigations include urinary microscopy and treat urinary tract infection if diabeteic to control blood sugar.to treat any respiratory tract infection The following methods are advised to all patients with incontinence, before any surgical measures are taken. In mild forms the success rate is quite good, in moderate to severe cases and in mixed incontinence, they should be tried before advising urodynamic studies and then surgery. Reduction in consumption of caffeinated drinks, smoking,and alcoholic drinks, should be encouraged. Fluid restriction if not contraindicated by their medical conditions can be attempted. Timed voiding to prevent filling the bladder capacity so that it does not leak during increase in intra abdominal pressure increase .This can be done with urine diary with intake , amount voided, amount leaked with activity, whether urge present or not. Pelvic floor exercises, or kegel exercises.are advised . This is voluntary focused contaction of levetor ani muscles for 3 to 5 seconds and relaxing, this should be done for 45 to 100 repetitions.per day and to do it for atleast 16 weeks. This will strengthen the pelvic floor and improve the muscle support to the pelvic organs and increase the closing force on urethra. She should be motivated to do so and also with the help of a physiotherapist. Biofeed back is an adjunct to pelvic floor exercise by using electronic pressure catheter.Electrical stimulation using intra vaginal electrodes is an alterantive method . all these methods facilatate the contraction of levator ani and to strenthen them. Vaginal pessaries can be introduced which will support and elevate the bladder neck is a good alternative.this young patient can be taught to take care of it to avoid ulceratuion and discharge and infection. Urethral plugs can be placed over the external urethral meatus, or transurethrally with internal ballon are also available. If she is in estrogen deficient phase, she ca have estrings ( vaginal rings with 5 to 10 micrograms per day )can be placed vaginally.
		Posted by Shakira B. Mon Jul 18, 2005 03:55 am
Urinary incontinence may cause significant loss of quality of life and psychological distress. The initial assessment includes history, physical examination and simple investigations to direct further investigations and treatment. Its onset, severity and impact on social life has importance in planning treatment. Potential Causes to be considered are:- Stress incontinence, DI, Retention Overflow, fistula, UTI, and medical conditions (DM, multiple sclerosis) I will ask the patient about following urinary symptoms: - Frequency, Urgency, incomplete voiding, painful micturation, it could help in distinguishing the various causes. Her drug history is important, as diuretics or antidepressants all of which can cause or aggravate incontinence. Her obstetric history: - mode of delivery, Big babies will give clue to the cause of incontinence. Physical examination may not be helpful in determining the cause of symptoms but can asses patient?s suitability for further investigation and treatment. P/A to look for a palpable bladder indicating urinary retention or pelvic mass which exacerbates stress incontinence. On Vulval inspection:- irritant dermatitis from contact with urine can be seen. Pooling of urine in vagina on P/S suggest fistula. Degree of oestrogenisation of vaginal skin is noted also. the presence of prolapse could lead to urinary leakage. Assessment of pelvic floor muscles, Anal Sphincter:- sensitivity of perineum & perineal area to touch and anal reflex is tested. Investigation at this visit include :- MSSU to exclude infection which could be eliminated by antibiotics. RV can be assessed by U/S or by catheter. As causes appropriate treatment is not evident from this initial assessment, further investigations could be arranged include IVU, cystoscopy and urodynamics. Non-surgical options of treatment are as follows:- It can be undertaken without urodynamic assessment either as mainstay of therapy or while awaiting surgery. Mechanical devises:- Urethral or Vaginal. In patients with infrequent symptoms. Management of Conditions associated with raised intra abdominal pressure such as Chronic Cough and Constipation may improve symptoms. Pelvic Floor exercise :- Is affective in improving symptoms, 27 ? 67%. Cure or improvement, but once discontinued high relapse. Physiotherapist interested in continence is essential as vague instructions to do ?pelvic floor exercise? are ineffective and may be counter reproductive. Use of electronical pelvic floor stimulation, bio feedback and vaginal cones is not associated with improved outcome when compared to pelvic floor exercises alone. Oestrogen replacement does not improve symptoms and is associated with side effects like nausea and GI symptoms and in long term increased DVT & Breast cancer Risk. Alpha adrenergic agonists such as phenylpropanolamine is as effective as pelvic floor exercises but are contraindicated in women with Hypertension, thyrotoxicosis, cardiac disease and associated with high discontinuation rates. A combination of oestrogen & phenylpropanolamine may improve symptoms in some women. No evidence that weight reduction reduces symptoms of stress incontinence or alters surgical outcome. Behavioral modifications:- A frequency volume chart can help patients with excess fluid intake and modification of fluid intake can be recommended. Constipation is associated with urinary incontinence and therefore women should be advised to maintain healthy bowel habits by increasing fluid and fiber intake. Bladder retraining, i.e. void on schedule associated with 57% reduction incontinence.
		Posted by hassan M. Mon Jul 18, 2005 06:30 am
Stress urinary incontinence effects 1 in 3 women. It is defined as involuntary leakage of urine on effort, exertion, sneezing or coughing. The impact of stress urinary incontinence on social functioning and quality of life can be extreme. Basic assessment should include a comprehensive, systematic inquiry of all relevant factors including chronic cough and constipation, increased fluid intake, professions related to lifting heavy weight, drug therapy that is diuretic and antidepressants, previous pelvic surgery, recurrent urinary tract infection and anorectal problems. Obstetric history is very important relating to route and mode of delivery, the time passed since the last delivery and if she had any post-natal exercises. History of labor of prolonged second stage, instrumental delivery and macrosomic baby is mandatory. Episiotomy and emergency LSCS does not protect against pelvic flow damage. Detailed general physical examination should be carried out, including body weight (to exclude abdominal mass), chest symptoms, rectocele, cystocele, uterine descent. Pelvic floor muscles are assessed and anal sphincter sensitivity to touch, pin-prick in perineal and peraanal region and illiciting bulbocavernous reflex and anal reflex. If patient is suspected to have generalized neurological condition, refer to neurologist. Investigations are done which include mid-stream urine to exclude urinary tract infection, quality of life questionnaire, and fluid volume chart to be given to patient to assess the impact of this problem on her life. X-ray chest is carried out to exclude chest infection. Pelvi-abdominal ultrasound scan is done to rule out presence of masses. First option available to this patient is physiotherapy of pelvic floor muscles. This treatment has no side effects but needs a highly motivated patient and a trained physiotherapist. PERFECT assessment scheme will ensure that each patient has an individualized exercise programme. Cure rate and improvement can be as high as 60%. Duration of treatment should be around 4-6 months. New drug called Duloxatine is marketed recently. No data is yet available regarding its effect with adjunctophysiotherapy. The patient should be informed about the side effects, which are GIT disturbances, headache, dry mouth, decreased libido and inorgasmia. Use of graduated vaginal cones has resulted in training of pelvic floor muscles. An attempt made to prevent it from falling produces a contraction of pelvic floor. It is used for 10-20 minutes each day while undergoing activity of normal living. Biofeedback allows patients to appreciate quality of their pelvic floor muscle contraction of which they are otherwise unaware. EMG biofeedback is available in many hospitals with one electrode placed in the vagina with indicator (periform). Neuromuscular electrical stimulation is aimed at pelvic floor and external urethral sphyncter. A vaginal electrode is used and patient is encouraged to accept a maximum current intensity for contraction of pelvic floor muscles. If above conservative treatment fails, patient should be counseled about surgical options following urodynamic investigation
		Posted by Vandana D. Thu Jul 21, 2005 12:59 am
Initial management comprises of establishing the likely cause of stress incon.,& severity of condition by detailed history,clinical exam.,investigations & offering non surgical treatment options. History:Duration of symptoms,request her to fill questionnaire on urinary incontinence-toassess its impact on her quality of life (social,sexual) ;chronic cough, smoking,chronicconstipation,urinary infection,backache(due to uterovaginal prolapse),problem of defecation. Obstetrical history:Mode of delivery,if vaginal,then history of prolonged labour,difficult delivery,forceps,big size baby-Birth wt of babies;interval between pregnancies,last delivery-has she recently had vaginal delivery? Personal history:caffiene intake.fluid intake. Medical history:Any illness as it may affect the medicines if prescribed for her problem,diuretics ,any neurological disease that may affect her urogenital organs & function,diabetes. Clinical exam:BMI,Temp.,Chest exam to detect signs of infection,PA exam:any mass contributing to rise in intra abd pressure,enlarged bladder due to chronic retention. Perineal exam:ask her to cough /strain ,it may or may not demonstrate incontinence,Per speculum exam:to assess prolapse of ant vaginal wall(cystocele),uterus,rectocele;bimanual pelvic exam:any pelvic mass,tone of pelvic muscles by asking her to contract her muscles,perineal sensations. Investigations:Pad test if incontinence could not be demonstrated on clinical exam.Urinary diary to record the episode,aggravating factors;maintenance of diary would also help in assessing her response to treatment. MSU for sugar, infection.Refer her to urologist for expert opinion.If appropriate consider simple cystometry to detect the likely cause of her symptom-GSI or DI or both. Non surgical methods should always be tried prior to surgical intervention.Mild to moderate incontinence usaully responds well to conservative management,at the same time avoiding the undesirable surgical sequelae. Treatment of cough,if recurrent chest infection-refer her to chest physician,reduce /stop smoking (if she is a smoker),Tt constipation-fibre rich diet,laxatives,wt reduction-if obese,-by exercise & dietary modification. Trial of incontinence ring-may benefit in cases where there is loss of bladder support. Patient education & pelvic floor muscle exercise(PFME) under supervision of pelvic floor muscle therapist/physiotherapist.Appropriate training can produce satisfactory improvement in upto 75% of cases.If needed biofeedback can be used.Patients who fail to achieve improvement may be offered electric nerve stimulation.Opinion of therapist must be sought. Patints who are not able to achieve symptom control may be given a trial of medicines -imipramine ,ephedrine,pseudoephidrine after excluding contra ind. to them(hypertension,hyperthyroidism,) Advise her to use contraception if she is not using any so as to avoid pregnancy until reasonable time to allow her to recover. Provide information leaflets.
		Posted by Vandana D. Thu Jul 21, 2005 01:03 am
I dont know how that icon has come ,I\'m sorry forthat.