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MRCOG PART 2 SBAs and EMQs

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ESSAY 204 - INCONTINENCE

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		Posted by Balakrishnan V. Thu Aug 3, 2006 09:07 pm
A detailed history should be taken regarding duration of symptoms, effect on daily and personal life and any aggravating factors. Which symptom bothering her the most and treatment should be aimed to cure that one. Abdomin should be palpated for any masses and perineum examined for signs of excoriation by urine and atrophic changes due to menoause which can give rise to these symptoms. Pelvic examination is done to rule out cystocele, asymptomatic first degree uterine prolapse or pelvic masses. Its very important to rule out urinary tract infection by culture and sensitivity of mid stream urine as its common and treatable cause of urgency, frequency and urge incontinance. Pelvic ultrasound will indicate any residual urine and pelvic masses. Her management involve detailed counselling and motivation as its long term and may need life style modification. She should keep urinary diary for two weeks which tell about her quantity and quality of fluid intake, volume of urine, episodes of urinary incontinance during day and night so her management can be tailored accordingly. She should restrict fluid intske to 1.5 liter per day. Caffine, alcohol and fizzy drinks which increases urinary output should be stopped or cut down. She can be given vaginal oestrogen cream which improve urinary urgency and frequency due to atrophic uro-genital changes. Use of bland emollients to protect the skin and incontinance pads can improves quality of life. Bladder retraining is done with the help of incontinance nurse. This involves trying to go to toilet at specified intervals which are prolonged as bladder capacity increases. Holding the urine in mid-stream also enhances urethral shincter and pelvic muscles tone. This has proven to be effective in 90% of the patients but no long term data is available. Pharmacological treatment can be tried in combination with general measures or alone. These have placebo effect and improve the symptoms. Anticholinergic like oxybutinin or tolterodine is given 20 to 40 mg twice daily. It causes dry mouth, blurred vision, drowziness, headache which limit its use. The new solifenacin is selective for bladder and do not effect salivary glands so have fewer side effects. Calcium channal blockers like propevarine, antidiuretic harmone analogues and tricyclic antidepressants can be used for nocturnal diuresis but there side effects limit their use. If her symptoms donot improve she should have urodynamic studies like cystometry to find the cause. Cystoscopy is needed if custometry indicate low bladder capasity. Surgery can be used if no response to other measures although long term success rate is low.Bladder distension under regional block for two hours improves these symptoms in 50% patients but there is risk of bladder rupture. Transvesical phenol injection and clam ileocystoplasty are other options but not without risks. Patient should be counselled regarding success rates, risks and relapse rate of various surgeries and her wish should be taken into consideration. She should be given information leaflets and continuouse support.
		Posted by Kishor S. Thu Aug 3, 2006 09:20 pm
Management will be guided by her history, examination and her expectations regarding the treatment. In the history, the degree to which her symptoms cause inconvenience and discomfort should be established. She should be asked about the intake of fluids including coffee/tea, if she smokes or drinks alcohol as they can contribute to her symptoms and to the outcome of treatment. A full medical and drug history whether diabetic, whether on diuretics (e.g. for hypertension), or whether in cardiac failure should be taken which might explain the frequency, and also to assess her fitness in the event she elects to have surgery. At this age she is expected to be postmenopausal and any history of HRT should be enquired as atrophic vaginitis can have urinary complaints. Any prior attempts to repair should be asked as it will influence the outcome of a repeat surgery, if needed. Regarding examination, her BMI should be calculated as weight reduction in obese woman may lessen her symptoms. Moreover, the risk for surgery e.g. VTE in obese woman may outweigh the benefit of surgery. Any abdominal or pelvic mass should be ruled out. Pelvic and speculum examination are required first with full bladder and then after voiding to confirm the absence of stress incontinence as it is one of the common association, and any pelvic organ prolapse. Urethral caruncle also should be ruled out. In the event of suspicion of neurological problem, a complete neurological examination by a neurologist is necessary. With regard to investigation, intake of fluids/ drinks (coffee/tea), a urinary diary and a frequency ? volume chart should be done. In detrusor instability, the volume voided is less than 150 ml with frequency (<2 h). Urine for microscopy and culture should be done to rule out UTI. USS will be required to assess the residual amount as in outflow obstruction, the residual volume will be more than 50 ml. Treatment will depend on the diagnoses, which could be UTI, detrusor instability, detrusor hyper reflexia secondary to neurological disease, psychological or unusual fluid intake. She should be first explained about the diagnosis. In the absence of any pathology, reassurance may suffice. Life style changes, reduction in caffeine intake and modification of medical treatment e.g. diuretics may improve the condition. Bladder drill is found to be effective up to 90% though there is 40% relapse within 3 years. Oestrogen cream vaginally may help in some but objective improvement does not occur. In the presence of UTI, appropriate antibiotics should be given. But if haematuria and bladder pain continue, cystoscopy should be done to rule out bladder neoplasm or interstitial cystitis. Detrusor instability can be treated first with medicine such as oxybutynin or tricyclic antidepressants though the side effects need to be explained to her. In cases where medical therapy fails and patient opts for surgery, the procedures which can be done include prolonged cystodistention (complication ? bladder rupture) and augmented cystosplasty (complication ? profuse diarrhea). Success rate can be as high as 90% but at the same there is 50% relapse in a few years. In the presence of associated medical and neurological problem she should be jointly managed with the concerned specialist. Lastly, non coventional therapy such as hypnotherapy has also been tried with some success. Whatever the form of treatment she should be followed up every 3 to 6 months to evaluate the response.
		Posted by neera B. Thu Aug 3, 2006 11:20 pm
Severity, duration of symptoms and their effect on her quality of life ; previous incontinence surgery or previos treatments should be asked. Alcohol, tea, smoking, history of prolapse, lump abdomen and age at menopause should be enquired. BMI should be noted ; abdominal ,speculum and vaginal examination should be done to assess the mobility of urethra, prolapse, pelvic mass and atrophic vaginitis. Mid stream sample of urine for culture and sensivity should be sent since urinary infection can cause these symptoms. Urinary diary should be maintained. Pad test should be done. If a pelvic mass is suspected ultrasound should be done as removal of large ovarian cyst or fibroid may alleviate her symptoms. Subtracted cystometry helps to differentiate between DI, SI and low compliance bladder. Fluid intake should be restricted to 1.5 litres per day; restricting the intake of tea, coffee, alcohol may control her symptoms. Fluid intake after 8:00PM should be discouraged to control nocturia. If BMI is over 35, weight reduction by diet and exercises is advised. If SI is coexistent,evidence shows that pelvic floor exercises are helpful. Reassurance and empathetic counselling is needed. MDT involving incontinence advisor and senior gynaecologist should look after her as this gives better results. Oral tolteridine 2 mg twice daily shoyld be advised since it is as effective as oxybutynin with lesser side effects. These act by inhibiting detruser contractility. If this fails, alpha adrenergic stimulants should be offered as these increase sphincter tone. Medical treatment is first line because it is cheap, effective and non-invasive. Imipramine or DDAVP nasal spray are helpful to control nocturia. Estrogens have not been found useful. Bladder retraining is as effective as oxybutynin in short term though relapse rate is high. It is alternative first line for patients not compliant or not willing to take medical treatment. In refractory cases, biofeedback, acupuncture, electric stimulation, transvesical phenol, cystodistension are options to be discussed with the patient they are effective but require trained personnel, and time; relapse rate should be discussed. Pamphlet should be given, patient should be involved in decision making and informed consent should be taken. 10% cases may not respond to any of these, so surgery should be offered. Clam cystoplasty is the most effective surgery for DI but side effects like mucus retention, malignancy in ileal segment are some of the risks. Detrusor myomectomy and urinary diversion are other alternatives.
		Posted by afroz S. Fri Aug 4, 2006 08:08 am
From the clinical symptoms this pt is most likely suffering from detrusor instability which is the second most common cause of urinary incontinence. Detailed history should be taken including the severity of the urinary symptoms. These symptoms may affect the quality of life including social & sexual life. Exclude neurological diseases such as multiple sclerosis. H/O excessive intake of alcohol and caffeine is taken. Also h/o previous surgeries on the urinary tract are enquired. Examination includes general physical examination, PA exam for abdominal masses or ascitis, PV exam to detect utero-vaginal prolapse, cystocele. Demonstration of stress incontinence is associated with DI. Investigations include mid stream urine for analysis, culture & sensitivity to detect UTI. Fluid volume charts to detect the severity of incontinence. Urodynamic tests are not required unless the treatment fails. Treatment includes counseling and re assuring the pt is important. Treatment of UTI with antibiotics depending on the sensitivity. Restriction of fluids to 1.5 Liter per day. Reducing the intake of alcohol, coffee or tea. Bladder retraining or drill where the pt should hold the urine for one hour even if there is leakage. Once this is achieved without leakage, then the duration is slowly increased to 1 1/2 hr,2 hr etc. The relapse rate is high with this type of treatment.Other T/t includes behavioural therapy and biofeedback. Acupuncture and hypnosis may be effective. HRT is not effective except in genital atrophy. Drug therapy includes anticholinergic drugs like oxybutynin which is administered orally but associated with side effects such as dry mouth, blurring of vision, constipation etc. These side effects may be reduced by intravesical route of administration of oxybutynin.Other drug is tolterodine. This drug has a better side effect profile. Other drugs include SSRI like fluoxetine ,antidepressant like imipramine may be effective in some pts. DDAVP[desmopressin] in mainly effective in pts with nocturia. If all these above measures fail surgical procedures may be required which includes Clam ilieo cystoplasty which is associated with complications such as carcinoma in enteric segment , electrolyte disturbances and voiding dysfunction. Cystodistention has a risk of bladder rupture. Ureteral diversion is the last resort which is associated with more complications. None of these surgeries have proved to be very much effective. Follow up is required to detect the success of treatment and any relapses.
		Posted by Ismatara B. Fri Aug 4, 2006 09:17 am
For proper management a history, examination and relevant investigation is needed. It is important to identify the severity and duration of symptoms and their effect on her daily and personal life, any distressing symptom, weather there are any previous surgery or previous treatments for incontinence. She should be asked about intake of any diuretic drugs, intake of fluids such as tea/coffee, alcohol, any H/O smoking, history of any prolapses as they can contribute to her symptom and outcome of treatment. Her lifestyle factor location of toilet and fiddly clothing should be asked. Full medical H/O diabetes or other neurological disease (multiple sclerosis) should be sorted out as these will help in management.Regarding examination her BMI should be calculated. Abdominal, speculum and vaginal examination should be done to rule out any genito-urinary prolapse ( cystocele), pelvic mass and atrophic vaginitis. If there is any suspicion of neurological problem, a complete examination by a neurologist should be done.Mid stream sample of urine for R/M/E, culture and sensitivity should be sent as urinary tract infection or diabetes mellitus can cause these symptoms. Fluid volume chart of intake output should be maintained, as this will indicate functional bladder capacity and severity of the disease. Ultrasound should be done if a pelvic mass is suspected because removal of large ovarian mass or fibroid may improve her symptoms. If there is haematuria, cystoscopy is indicated to rule out interstitial cystitis or neoplasm. Urodynamic investigations are not indicated unless the supportive and medical treatment has failed. If there are UTI, haematuria, mass or prolapses, should be managed accordingly, if not the diagnosis will be Detrusor instability (DI). At first incontinence advisor and senior gynaecologist should involve as this gives better results. Explanation of the condition to the patient is necessary as sometimes reassurance and empathetic counseling may improve the symptoms. There is 50% success rate in all treatment but relapse rate is high. Her lifestyle should be changed:restriction of fluid intake up to 1.5 liters per day; avoidance of tea, coffee, alcohol may control her symptoms. Toilet should be attached and different clothing may improve quality of life. If BMI is over 35, weight reduction by diet and exercises is advised as this may help to reduce her symptoms. Antibiotics if UTI. If SI is coexistent, evidence shows that pelvic floor exercises are helpful. Bladder drill +/- biofeedback is effective, (60% improvement) if the patient continue this at home but is costly. Medical (oxybutinine, Tolteridine) is first line treatment because it is cheap, effective and non-invasive (57-71% improvement rate). They act by inhibiting detruser contractility and are anticholinergic drugs. But Side effects like dry mouth, constipation, visual disturbance, voiding difficulties limit their use. Tolteradine is better-tolerated and effective. For patient using clean intermittent self-catheterization (CISC), intravesical oxybutinin provides the benefits with minimal side effects. Imipramine or DDAVP nasal spray is helpful to control nocturia. Though estrogens replacement relieves urogenital atrophy but has not been found to be useful in DI. If above measures fail then Surgery: urethral dilatation is not done due to its limited benefit. Prolonged cystodistension under regional block may help but there is risk of bladder rupture. Clam ileocystoplasty provides up to 90% symptomatic relief, but are associated with risk of ileus, wound infection, bowel obstruction, repeated UTI, malignant change in enteric segment, malabsorption and risk of voiding dysfunction (40-100%). Ureteral divertion is the last resort as associated with more complication. In refractory cases, hypnosis, acupuncture, electric stimulation, transvesical phenol are other option, they are effective but require trained personnel. Patient should be involved in decision-making by discussing success rate, relapse rate and complications of various treatment and informed consent should be taken. Active patient involvement and patient control management plan improves the outcome. The patient should be followed-up at every 3-6 months to evaluate the response. If failed treatment, cystometry should be done to exclude GSI and managed accordingly.
		Posted by Srivas P. Fri Aug 4, 2006 10:28 pm
It is important to find out about severity of symptoms, duration of her complains, any prior incontinence surgery, history of childhood enuresis and the effect of her symptoms on quality of life which can be assessed using questionnaires. She may face social embarrassment and avoiding social gatherings, outings and may be running to toilet as precaution to avoid incontinence. Her usual intake of tea, alcohol, caffeine should be asked and any diuretics if she is taking should be asked for. Examinations should be directed to look for vaginal excoriations, incontinence on coughing, excessive vaginal discharge which she may mistake for urine, presence of cystocele, signs of vaginal atrophy, pelvic masses and examination of cranial nerves to rule out neurological lesions. Investigations should include MSU for microscopy and haematuria and/or Multistix strips to test for nitrites blood and leucocytes, Culture and sensitivity to see urinary infections, Frequency volume charts to assess volume intake by maintaining a urinary dairy,24 hr pad test or if not convenient 1 hr pad test after 500 ml water should be done. Uroflowmetry is a simple noninvasive inexpensive outpatient investigations and the urine flow rate may be high in DI with a short voiding time. Cystometry can be done if she fails to respond to medical treatment. If urine shows haematuria a urethra-cystoscopy is indicated to look for bladder stones, cystitis with bladder thickening, bladder diverticula and urethral diverticula. USG should be done to see residual urine, pelvic masses, bladder calculi thickened bladder walls. Management involves general measures like restricting fluid intake to 1-1.5 liters, avoiding tea caffeine alcohol and diuretics if possible. Bio feedback, bladder drills and hypnotherapy have been found to be useful. If she does not improve with these measures anticholinergics like Tolterodine can be tried. It decreases bladder contractility but has side effects like dry mouth, constipation, tachycardia and blurred vision. Trospium a quaternary ammonium compound is effective with lesser side effects and increases bladder volume. Oxybutinin has anticholinergic and direct muscle relaxant effect and is effective in producing 70% improvement but causes severe dry mouth as side effect. If she is still not fully controlled alternative treatments like acupuncture may be tried and has been found to be useful but is time consuming. Surgery is the last option if all these measures fail and she must have cystometry before resorting to surgical measures to make definitive diagnosis. The only surgical options for DI if confirmed on cystometry following failed medical treatments are clam cystoplasty, and detrusor myomectomy. The latter does not decrease frequency though incontinence is taken care off. Following Clam cystoplasty she may require intermeittent self catheterization and there is 5% risk if adenocarcinoma in uretero sigmoidoscopies. If both DI and Stress incontinence exist in her as seen by cystometry it is better to treat DI with general and medical measures before resorting to surgery for Stress incontinence. Through all this she needs psychological help and empathetic counseling and explanations for line of management planned through leaflets and information brochures and referral to support groups.
		Posted by Vinayak B. Fri Aug 4, 2006 11:41 pm
Probable diagnosis is derusor overactivity due to detrusor instability. Usualy it is idiopathic ,precipited at old age due to poor child hood training or psychological stress.or change in life styles( change of house) History taken regarding nature and duration of symptoms its effect on quality of life whether she has to take incontinent pad which will suggest severity of symptoms . details of any previous treatment for these complaints . on any medications(diuretics) is enquired . Any History of surgery for stress incontinence asked as it may precipitate undiagnosed detrusor instability .medical history of hypertension/ cardiac iseases/ ophthalmic problem enquired which will modify drug treatment. Examination done to exclude any abdominal pelvic masses as it will give sensory detrusor instability. Pelvic examination done to exclude uterovaginal prolapse as cystocele associated with recurrent UTI producing frequency and urgency . No Clinical signs to establish diagnosis of detrusor instability. Basic investigations Midstream urine microscopy and urine culture sensitivity done and treted with appropriate antibiotics. Patient should be counselled about nature and probable diagnosis ( detrusor instability) which will help patients compliance for the initial treatment . Majority of patients will improve with conservative therapy and medical therapy. Special urodynamic investigations and cystoscopy may be required in due course if symptoms persists or surgical intervention needed . , Patient is asked to maintain .Frequency volume chart to know severity of symptoms.Excessive fluid intake should be avoided Caffine , tea alcohol , should be avoided.Advice and training from incontinence counsellar arranged .. Bladder training done with biofeed back .with audio / visual signals . Combined with pelvic exercises as coexistant stress incontinence .. Done for 3 to 6 mths . during training pads or emollient cream can be used . 80 to 90 % become continent.. 40% may recure againin 3 yrs. Patient should be motivated through out the programme. Drugs commonly used are anticholinergic, antimuscarinic agents.( Oxybutinin, Tolterodine Trospium ) use is restricted due to side effects such as dry mouth , constipation, diarrhea abdominal pain , headache dizziness drowsiness blurred vision, and etension of urine. Tolterodine and trospium less side effect and accepted by patient sustained relese preparation of oxybutinin is with same efficacy but less side effects.Selective m3 receptor drug Solfenacin will be drug of choice if available . Tricyclic antidepressant are effective in nocturnal enuresis and stressful condition . use restricted due to side effects such as ventricular arrhythmia and orthostatic hypotension. In few postmenopausal patients symptoms improve with estrogen if frequency due to genital atrophy . If still patient is symptomatic appt at urogynecologist should be arranged. few patient may improve with cystodistension where prolonged pressure on nerves chances of bladder rupture. Clam Augmentation cystoplasty or urinay diversion as last resort . Increase chance of adenocarcinoma and intractakle diarrhea seen with cystoplasty . Patient wishes to be considered .leaflets given.
		Posted by Freha Z. Sat Aug 5, 2006 07:48 am
The management of the patients involve assessment of severity of symptoms like nocturia or frequency, duration and effect on quality of life, fluid intake. She should be examined for any abdominopelvic mass or any uterovaginal prolapse. Her mid stream urine should be done and infection should be treated. The simple non invasive pad test provides more objective quantification of symptoms. Frequency volume chart allows objective analysis of symptoms. Pelvic scan should be done to rule out pelvic mass. Treatment options include conservative measures like advising cutting down drinks or altering the time at which drinks are taken. But severe restiction is not indicated which in combination with frequent voiding can lead to reduced functional capacity. Caffeine drinks should be advised against. Bladder retraining (voiding at intervals) without any pharmacological agent has cure rates between 44 and 90%. Pelvic floor exercise with bladder retraining can alsobe helpful. Medical therapies like anticholinergicscan help in57-71% but use can be limited by side effects i.e dry eyes, dry mouth, constipation and tachycardia. Antidepressants are particularly useful in treating symptoms of nocturia and nocturnal enuresis but they can cause orthostatic hypotension and ventricular arrhythmia. Oestrogen may be helpful to treat symptomsof urgency and urge incontinencealthough few clinical trials support their use. Surgery can be tried only if all other measures have failed . Prolonged cystodistension produces ischaemic nerve damage upto 2 hour. Augmentation cystoplasty needs careful counsellingbecause of risk of adenocarcinoma in the enteric segment. All treatment modalities have significant relapse rate and only 50% will notice an improvement. All the modalities should be discussed with the patient and she can make informed choiceabout her problem.
		Posted by Aroosha B. Sat Aug 5, 2006 08:59 am
Aim of management of this woman is to relieve her of urinary symptoms which would require a detailed history , examination and investigation to assess the severity of symptoms and to rule out associated causes . I will take a detailed history about severity and duration of her symptoms and affect of these symptoms on her quality of life.History of excess intake of fluids and caffeine is to be asked and lifestyle factors such as location of toilet is to be inquired. She will be also asked about signs and symptoms of vaginal prolapse like heaviness in perineum and some thing coming out of vagina although it is not much likely in this healthy looking lady but it is important to rule out . I will also ask about any symptom of UTI like dysuria , suprapubic pain etc.As regards the drug history and medical history , they appear to be not relevant in this case. Regarding her examination , GPE, maybe unremarkable .but local examination is important to rule out abdominopelvic mass and uterovaginal prolapse which can be coducive to above symptoms Her investigation would include urinary dipstick for blood , protein , leukocyte , nitrates , glucose and msu to rule out UTI. If clinical pelvic examination is inconclusive, I will request pelvic USG to exclude any pelvic mass. Urinary frequency volume chart is also requested which can detect episodes of leaking and give us an idea of the capacity of urinary bladder. Meanwhile it can also exclude overdrinking as its possible cause. In the absence of any pelvic mass or UTI, likely diagnosis is detrusor instability.The patient would be informed of the diagnosis and reassured that this is not a serious condition but the problem may be chronic and would require a long term treatment , multidisciplinary approach and active involvement of the patient. As regards her treatment there is no single treatment which could be first line and there is significant placebo effect in all kinds of treatment with 50 percent of success rate and high relapse rate. Different options of management include general measures like advising her to decrease intake of fluids , caffeine and lifestyle modification like change of location of toilet .Other option of management are behavioral therapy like bladder training and bio ?feedback which are the most successful forms of therapy (about 70 percent success).But they are time consuming and require mostly inpatient treatment and are costly. The drug treatment mainly include the anticholinergic drugs like Propanthline bromide , oxybutynine and teleterodine . Their side effects include dryness of mouth , constipation , visual disturbance, voiding difficulty which may limit the compliance although they have a success rate of 50 to 70 %. Other drugs like tricyclic antidepressants have been found useful in coital incontinence and DDAVP in nocturnal enuresis but their side effects and tendency to relapse limits their usefulness. As regards HRT it is effective in relieving symptoms of urogenital atrophy but are not found to be effective in DI instability. If above empirical treatment fails in this patient , I will do Urodymainc Studies before opting for surgry which would further require input from urologists ,general surgeon. Surgical procedure include urethral dilatation but is of limited benefit .Prolonged cysto distention under regional block is also effective but risk of bladder rupture is to be explained. Clam enterocystoplasty is the most effective surgical option but associated with risk of voiding dysfunction and malignant change in enteric segment is to be explained to the patient . Above different options of treatment are explained to the patient and her wishes are respected but in any case follow up of treatment is necessary as they are associated with high relapse.
		Posted by SWATI M. Sat Aug 5, 2006 05:27 pm
Her symptoms suggest that the most likely diagnosis is detrusor instability and treatment should be offered as it affects social life and compromises quality of life. History should be obtained and examination should be performed to determine the etiology and contributing factors to her symptoms to help in management. History should be enquired about the most troublesome urinary symptom , amount of fluid and caffeine intake, use and type of HRT ,use of diuretics if hypertensive, symptoms of utero-vaginal prolapse should be obtained. Determine her BMI, measurement of BP if hypertensive, abdominal palpation for any abdomino-pelvic mass should be done.Assess if any utero-vaginal prolapse and condition of vaginal wall for atrophy. Investigations include MSU to rule out UTI and bladder diary of frequency ?volume chart which may help determine cause. Treatment includes counseling , explanation of condition that serious pathology does not exist may suffice if her symptoms are mild. Explain that treatment may be required long term and relapses are common after discontinuation .This may help improve her compliance to treatment. Weight reduction should be adviced if high BMI which involves dietary manipulation , advice from dietician ,changes in life style and exercise.Restrict fluid intake to 1.5 to 2 lit /day and advice reduction in caffeine- tea and coffee and alcohol.Consult physician to change diuretic and offer alternative without compromising efficacy. Bladder drill which involves voiding at fixed intervals should be adviced with help of continence nurse and time interval should be increased gradually. Medical treatment should be offered if symptoms persist Anticholinergic drugs such as oxybutinin should be given if no contraindication - cardiac problems, glaucoma.Side effects such as dry mouth ,blurring of vision may be troublesome .If side effects are unacceptable ,drugs such as tolterodine or trospium chloride which has less side effects should be given. For nocturia imipramine should be given which is effective and also has sedative action.For urinary frequency and urgency ,local estrogen cream should be prescribed. Long term treatment may be required hence once symptoms are controlled ,long term treatment should be by bladder drill to minimize side effects of medical treatment. Assess her at regular interval and provide information leaflets. If her symptoms persist urogynaecologist must be involved in her care.Urodynamic studies must be performed to confirm diagnosis and surgery should be offered for intractable ,persistent symptoms which includes uretral dilatation or augmentation cystoplasty or urinary diversion.
		Posted by OJO AJIBADE . Sat Aug 5, 2006 09:58 pm
The most likely diagnosis in this lady is Destrusor instability.(DA) Since the woman is healthy one will inquire about the duration of the symptoms;effect on social and daily life activities.Amount ;frequency and type of fluid intake will be noted. Is she taking HRT to alleviate menopausal symptoms. Her BMI will be calculated and will be examined to exclude organic causes e.g abdominal or pelvic mass.Perineum will be examined for atrophic urethra and vaginitis;mild degree of cystocele or uterine prolapse as these may produce her symptoms.Neurologic examination will be done to exclude neurological problems eg Multiple Sslerosis -a common cause her urinary symptoms. Urinary trcat infection is common in this age group and will be excluded by culturing of mid stream urine.Ulrasound will be performed to exclude pelvic masses and determine the residual urine.If obesse she will be advised to loose weight as this will improve urinary symptoms.If urine culture is positive ;appropriate antibiotics will be given and she will followed up in the clinic.If culture is negative;she will be reviewed in 3 days with a bladder diary after educating her about its use. On review she will be started on anticholinergic agents eg oxybutinin for 3months after informing her about the side effects of the drug which include dry mouth;drowsiness constipation and dizziness.She will also be refered for bladder retrainig and pelvic floor exercise.This has been shown to improve those with destrusor instability. She will be reviewed in the clinic in 3 months and if symptoms improve she will be continued on this but if not she will be refered for urodynamic studies.If the latter confirms DA then the dosage of the drug will have to be adjusted to alleviate symptoms without increasing the side effects. If no inprovement she will be informed about long term intermitent self catherisation if she wishes. Other options available for her are surgical options involving bladder augmentation eg clam cystoplasy.This is a major operation with anaethetic and surgical complication risks.She is prone to excessive mucus secretion from the ileum sutured to the bladder. Oher surgical options is urinary diversion but this is rarely accepted because of its attecedent complications. Botulinum toxin injection into 20-30 sites on the desrusor muscle to cause its paralysis and therefore cause its relaxation has been in use and has been shown to cause improvement in 80-90% of patients. Overall treatment depend on motivation;her wishes and information leaflets given and follow up arranged.
		Posted by adnan S. Sun Aug 6, 2006 07:35 pm
The most probable diagnosis is over active bladder.History is obtained to assess the severity of her symptoms and their effect on quality of life,any exacerbating factors likeh/o excessive intake of coffee,tea,and cola as these are bladder irritants which increase her symptoms .H/o taking excessive fluids ,h/o taking drugs like diuretics as these increases urine output.History is obtained regarding life-style factors such as location of toilet and fiddly clothings.Previous h/o incontinence surgery is also enquired. Examination is done to exclude abdomino-pelvic mass and to detect utero vaginal prolapse.Following investigations are requested MSU and dipstix for blood, proteins,leukocytes ,nitrates,and glucose to r/o UTIand diabetes mellitus.Fluid volume chart indicate severity and functional bladder capacity.Pelvic scan to exclude pelic mass if inadequate clinical pelvic assessment.Cystoscopy if heamaturia on MSU.Urodynamic investigations not indicated unless failed treatment. Aim of the treatment is to improve quality of life with minimal complications or side effects and risks,as incontinence is not a life threatening condition.A multidisciplinary approach to the treatment in order to re-inforce advice,institute treatment (particularly behavioral therapy) and provide practical support,a continent advisor or a nurse specialist is an essential member.Explanation of diagnosis with reassurance that there is no serious pathology may suffice in some women.Life-style changes such as location of toilets ,change in type of clothing ,reduction of caffeine intake may improve quality of life.Bladder drill and bio-feedbackis effective in 90% but 40% relapse rate within 3years ,better outcome with in-patient treatment but costly. Medical therapy is an important adjunct to behavioral therapy,although there is no single drug which should be consider first line .There is significant placebo effect associated with all treatment.Anti-cholinergic agents are mainstay of medical therapy oxybutynin, tolterodine,propiverine,and solifenacine with improvement of 57%-70%.Significant side effects include dry mouth, constipation ,visual disturbances and voiding difficulties which may reduce compliance.Solifenacine is a newer agent with organ selectivity for the bladder over the salivery gland,similar efficacy to other agents and less side effects especially dry mouth .Tricyclic antidepressants have anti-cholinergic effect and also sedative ,useful in nocturia and nocturnal eneuresis ,the main side effects are drowsiness and postural hypotension.Oestrogen are effective in relieving symptoms of uro-genital atrophy,but no evidence that it is effective in proven OAB, Surgical treatment like urethral dilatation is of limited benefit.Prolonged cysto-distension under regional block is effective but carries the risk of bladder rupture.Augmentation cystoplasty associated with risk of voiding dysfunction and malignant change in enteric segment. Follow-up is essential as poor success rate with treartment and high relapse rate.Failed empirical treatment is an indication of cystometry.
		Posted by Samir A. Thu Aug 10, 2006 09:10 am
This woman probably has detrusor instability(DI),however I should exclude mixed DI with genuine stress incontinence(GSI) and urinary tract infection. I\'ll take history of onset, duration and severity of symptoms, LMP, bladder pain, frequency, nocturia, stress incontinence, dysuria, haematuria and ask in a senistive way about nocturnal enuersis (now and in chlidhood) and incontinence during coitus. I\'ll ask about history of previous incontinence surgery, drug history(diuretics, parasympathomimetics), excessive alcohol, caffiene or fluid intake and the efffects of symptoms on her social life. I\'ll examine for pulse, BP, BMI, suprapubic tenderness, pelviabdominal mass, urogenital prolapse and menopausal genital atrophic changes and evidence of stress incontinence (passage of urine on cough). I\'ll ask her to do frequency-Volume chart, urine dipstix (for leucocytes,RBCs,protein,PH), MSU. I\'ll do pelvic scan if I feel pelviabdominal mass or if could not do adequate pelvic assessment. I\'ll arrnge for urodynamic studies if she had previously failed medical treatment, mixed stress incontinence is suspected or before surgery.However empirical treatment could be started in cases of mixed stress incontinence. if she has haematuria, bladder pain or reduced bladder capacity at cystometry I\'ll arrange for cystoscopy. If the diagnosis is DI (most probable in this case) or even mixed stress incontinence I\'ll start empirical treatment. No single treatment is cosidered as first line of treatment since comparison between published trials is difficult and the available RCTs are few.There is a significant placebo effect with all treatments. I\'ll explain and reassure that there is no serious pathology since this helps in the managment, advise for life style changes (change of toilet location, types of clothes, reduction of alcohol and caffiene intake. Bladder drill and biofeedback are very effective since 90% of patients become cotinent.However 40% have relapse in 4 years and expensive. Medical treatment by anticholinergic (Oxybutinin, Tolterodine, propiverine, Slifenacin), give 60% improvement.Side effects (nausea, vomiting,diarrhoea, abdominal pain,dry mouth, dry skin, blurred vision, voiding difficulty, headache, dzziness,disorientation skin rash, arrhythmia, angio-oedma) are limiting factors, however they are less in Solifenacin since it is selective for the bladder over salivary glands, however long term data are not yet available. Tricyclic antidepressants gives improvement through its anticholinergic effect, but more useful in nocturia and nocturnal enuresis. Side effects include postural hypotension and drowziness. Antidiuretic hormone (DDAVP) is effective also in nocturia and nocturnal enuresis. Side effects include hyponatraemia,nasal congestion and epistaxis. Estrogen (Topical) is effective in relieving symptoms of urogenital atrophy in post menopausal women (frequency,urgency, dysuria), but no evidence that is effective in DI. If medical treatment fails, I\'ll counsel the patient for surgical treatment options. Uretheral dialtation has limited benefits but low complications.Prolonged cystodistension (2hours under regional block) gives 50% improvement but has the risk of bladder rupture. Augmentation cystoplasty makes 90% of patients continent. However it causes voiding difficulty in 25%, and 15% of patients require self catheterisation and has the risk of adenocarcinoma of the enteric segment as well as profuse diarrhoea. Hypnotherapy is another choice and may be effective. In general, all treament modalities have significant relapse. However 50-60% of women would have notice improvement.