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MRCOG PART 2 SBAs and EMQs

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EMQ1502
SBA2115
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Essay 280 - urinary incontinence

Posted by Farzana N.
a)Detailed history is taken about duration and severity of her symptoms. aggravating and relieving factor. Symptoms of urge,frequency and nocturia should be asked as DI may be overlapping with GSI.Enquiry should be made regarding impact of her symptoms on her social life, and any symptoms of prolapse .History of fecal /flatus incontinence also taken as the woman may not volunteer to inform. Voiding difficulty such as hesitancy or poor stream enquired.
Obsetric history regarding her parity,mode of deliveries is taken,particularly any difficult vaginal deliveries,withthird or fourth degree tear.Woman should be asked if she has completed her family.
Medical history regarding chronic respiratory diseases and constipation ,neurological disease or cardiac failure for which she is receiving diuretics should be taken. Any previous treatment taken or surgeries done.
Symptoms such as visible hematuria,recrrent or persisistent UTIs,voiding difficulties would require specialist referral,as also associated fecal incontinence, neurological disease, previous failed continence surgery ,previous pelvic cancer surgery or radiation therapy.
b)Clinical examination should make note of her weight and height,as raised BMI is a contributing factor for UI.
Abdominal examination for any abdominopelvic mass.Vulva lskin excoriations and ammoniacal smell noted due to irritation of skin with urine.Vaginal examination done for any adnexal masses, and mobility of anterior vaginal wall.Speculum examination for presense and degree of any prolapse.
c) Initial investigations include bladder diary for three days covering variations in normal day-to-day activities.Urine dipstick for blood,glucose, proteins,nitrites and leucocytes .
d)If conservative methods have failed ,woman should be offered surgical treatment.
Before surgery ,urodynamic studies should be done.
Surgical treatment includes mid-urethral sling prodcedures using TVT-knitted prolene mesh tape .can be performed under local anesthesia. With complete dryness 38% .success rates 85-90% at5yrs .Long term data are not available. Complications include risk of bladder injury in 8% of cases.
Retropubic procedure open colposuspension is another option with high sussess rate,85-90% at 1yr and 70% at 5yrs.Complications are De novo DI 17%.voiding difficulties 10% and enterocele or rectocele formation in 10% .
Trans obturator sling can be placed using inside- out(from vaginal incision to skin) or outside –in technique. By appropriately trained specialist.It is comparatively new technique which has shown efficacy,but long term data are not available.
Other option is Intramural bulking agent such as collagen , silicone or carbon coated zirconium beads.Their efficacy decreases with time and they require repeated injections. Have lower success rates than retropubic or sling procedure.
Artificial sphincter useful in failed surgery but is associated with high morbidity.
woman should be given written information about the different treatment options and consent obtained. surgical procedures should be undertaken by trained surgeons.


Posted by shree D.
A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks]
I would ask how frequent the symptoms are, and when they occur (at night, on lifting). I would exclude the presence of hameaturia adn dysuria, and ask how long the symptoms have been present. Relevant medical history includes previous surgery, medications which can cause incontinence, the patient\'s fluid intake (including amount of caffeine), whether the patient smokes, her BMI, and other issues such as the presence of a chronic cough or constipation. Mode of delivery is also relevant. I would ask if the patient feels a lump \"coming down\" during the day.

I would also consider a quality of life assessment, in order to quantify the impact of her symptoms on her lifestyle

(b) What information would you obtain from the clinical examination [2 marks]

I would check the patient\'s BMI and ascertain the presence of vaginal wall prolapse or uterine prolapse. This can be done using a Sims speculum and the POPQ score. If there is uterine prolapse, I would like to quantify the extent of the prolapse. I would also liek to exclude urethral diverticulae on palpation of the anterior vaginal wall.

(c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks]
I would recommend a MSU to exclude infection and consider a fluid balance diary. Urodynamics and cystoscopy may be considered as second line.

(d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence. Evaluate the subsequent treatment options [6 marks].
Medical management in the form of duloxetine may be helpful. However, this is commonly associated with side effects such as difficulty urinating and dry mouth, and has a low success rate. It is thus suitable for someone who is not fit for surgery or declines surgical intervention. Surgical management in the form of daycase procedures such as TVT or colposuspension are first line surgical treatments. These can be done under regional anaesthesia. Success rates are high, around 85% from initial data. However, complications such as urinary retention and urinary dysfunction may occur in the short term. Bladder perforation is also possible. TVTs use synthetic material, which can erode with time. Laparoscopic colposuspension is possible, although operation times are often longer and a skilled surgeon is required.

If there is associated vaginal wall prolapse, anterior or posterior repair can help ameliorate the symptoms, although there is limited success on incontinence if there is no prolapse.

Injectable agents can be considered as well as suburethral slings, although these require long-term followup with little data on the results available.
Posted by Osman A.
a)Severity of her incontinence especially if it is affects her quality of life should be obtained. Mixture symptoms like urgency, frequency and nocturia may suggestive of combination overactive bladder. Any history of chronic constipation or cough should be noted. Bladder symptom like haematuria or bladder pain should be assessed. Previous history of treatment in a form of incontinence surgery or medication is important. Fertility wishes will determine type of treatment. Obstetric history of previous instrumental delivery or big baby should be asked.
b) Presence of palpable bladder or pelvic masses should be assessed. On pelvic examination, presence of excoriation or inflammation due to prolonged contact with urine indicated of severe incontinence. Evidence of uterovaginal prolapse and cystocele should be examined.
c) Ultrasound should be done as clinical examination can be difficult to assess pelvic organ. Urine feme and urine culture should be sent to rule out underlying infection. Urodynamic should be done.
d) Duloxetine is a combination serotonin and noradrenalin reuptake inhibitor. It is proven to improve continence rate but it has side effect like dry mouth, headache and decreased libido. It is suitable for those who have not completed family. Burch Colposuspension is surgical intervention and it has continence rate of 80-90%. It is associated with bladder perforation, voiding difficulty (5%) and denovo Detrusor Instability (DI). Sling procedure (eg TVT), the aim is to improve the urethral pressure. It is associated with bladder perforation and voiding difficulty and the continence rate is 85-90%. Trans-obturator foramen procedure has good efficacy but not easily available.
Posted by S D.
a) Duration of symptoms and its severity and effect of symptoms on quality of life is important. Other urinary symptoms such as frequency, dysuria, urgency and urge incontinence should be enquired. Any bowel symptoms such as incomplete emptying, constipation or bowel incontinence should also be asked. History of feeling of lump inside vagina and any sexual difficulties should be asked. Past obstetric history including mode of deliveries, duration of labour and size of babies is important as urinary incontinence is precipitated by prolonged labours. Her intentions for future child bearing should be asked. History of smoking, alcohol, amount of coffee or tea and fluid intake should be asked. Any drug intake such as diuretics is important. Any treatments taken and their effects should also be asked.
b) Her BMI should be done. Abdominal examination to look for any palpable masses or tenderness and vaginal examination to look for uterovaginal prolapse and any uterine and adnexal masses as well as demonstration of stress incontinence by asking the woman to cough.
c) Investigations include urine dipstix to look for nitrites, blood, leucocytes and protein. MSU should be sent. Bladder diary is important as it gives information on functional bladder capacity, fluid intake and number of episodes of incontinence. Cystoscopy should only be done if there is blood in urine on dipstix or frank haematuria. Urodynamics is not indicated unless there is mixed incontinence or prior to surgery for stress incontinence.
d) The woman can use intavaginal devices, urethral plugs for certain situations such as for parties. Medical treatment such as phenylpropanolamine has been shown to decrease the frequency of incontinence episodes and improve quality of life but is associated with severe side effects such as vomiting, diarrhea, blurring of vision which limits its use. Also there are no long term data on its use. Surgical treatment options are mainly TVT and Bursch colposuspension. Bursch colposuspension is the most effective procedure for stress incontinence. It has an objective success rate of 80-90% at 1 yr which decreases to 70% at 5 yrs. Complications include detrusor instability of 14% and voiding difficulties in 12% of cases. Laparoscopic colposuspennsion is as effective but expertise is required and long term results are not available. TVT and TOT have success rates of 80%. TVT is associated with bladder perforation in 8% of cases and there are no long term data for TOT. MMK is an effective procedure but has fallen out of favour because of occurence of osteitis pubis in 2.5% of cases which is difficult to treat. Needle suspension procedures are no longer used as they are associated with high failure rates. Bulking agents such as collagen, teflon are associated with low morbidity but high failure rates and repeat procedures are necessary.
Posted by Ron C.
A.
To what extent do her complaints affect her; for example is her social or working life compromised. How long has the problem been there and how often does she have an “accident”. Exact nature of complaints; any urge component present, dribbling, incomplete emptying or even straining on voiding. Does she have precipitating factors; constipation, chronic cough (astma, smoking), sedentary life style, connective tissue disease (or in family), long labour, instrumental delivery, macrosome babies. It is important what she so far has done already to address the problem. Enquiry on plans for future pregnancies and identification of medical problems or previous surgery that would render her less suitable for surgery.
B.
Weight and height for BMI. Focus on abdominal, vaginal and speculum examination; assessment needs to identify any pelvic masses, visible prolapse or leaking on straining, presence and degree of cystocele, enterocele, rectocele or uterine descensus. Speculum examination is done with Sims speculum in supine and lateral position and rating is based on the POP-scale (ie distance of deepest part of prolapse in relation to hymen remnants). Pelvic floor muscles can be tested by letting patient tense her pelvic floor during vaginal examination.
C.
Most basic investigation is testing midstream urine to identify (recurrent) urinary tract infections as cause or contributing factor. In absence of any findings, an ultrasound kidney-ureter-bladder to rule out abnormalities is worthwhile as well. Urodynamic investigation including flowmetrics is indicated if surgery is already anticipated.
D.
Medical treatment to increase sphincter tone are mostly serotonine & noradrenalin re-uptake inhibitors (ie duloxetin 20 mg bd). Though they may be effective in some patients, its use is not widely established and limited by side-effects, such as constipation, nausea, urinary retention. Surgical approach could be colposuspension. Both Marshal Krantz and Burch have good 1 and 5 year result (89% resp. 80%), and resolve possible cystocele at the same time. Up to 18% will develop eneterocele though, there are 12 % new-onset urge-complaints and 12% voiding difficulty, and in Marshall osteitis. Sling procedures such as TVT have similar results, same number of new urge- and voiding problems, but no increase of enterocele. There is higher risk for perforation of bladder or bloodvessels (obturator) and erosion of the prolene or mersilone mesh in small numbers. Anterior colporaphy and needle suspension with Stamey needles are effective, but rates at 5 years are poor. Their relative simplicity and low-invasive character though may be an advantage for fragile elderly or high risk patients. Peri-urethral injection of silicone particles works in about 50%, but again poor long term outcome and expensive. Again, being low-invasive makes it suitable for high-risk patients. Artifical sphincter yields high long term results, but 50% of patients runs into complications of infection or erosion, requiring surgical revision in 1/3.
Posted by Manoj Babu  R.
(a)A detailed history should be taken regarding the onset, duration, severity and effect of the urinary leakage on the quality of her personal and social life. Any associated urinary symptoms like urgency, urge incontinence (UI), features of UTI like dysuria, frequency of micturation should be asked for. Any history of fecal or gaseous incontinence should be asked for, specifically. Past history of chronic cough, connective tissue disorders, neurological disorders can give clues regarding the etiology. History of diabetes, hypertension, or any drugs like diuretics is important. Her parity, mode of deliveries, weight of pervious babies, h/o prolonged labors, perineal trauma is also important. Any past surgeries including previous surgeries for hernia repairs, stress incontinence is to be asked.

(b) General examination should include calculation of BMI as obesity is a risk factor for SUI. Abdominal examination for any hernias, masses as these are risk factors for incontenance. Local examination to look for any uterovaginal prolapse, tone and strength of pelvic floor muscles.

(c) Bladder dairy should be maintained for three days which should include holidays will give more details of her symptoms. A urine dipstick for protein, sugar, pus cells and nitrate should be done. If symptoms of UTI are present do an MSU for culture and sensitivity and consider empirical broad spectrum antibiotics pending culture report.

(d) Treatment options for SUI after unsuccessful conservative treatment include surgery, medical treatment and rarely procedures like artificial urinary sphincters and bypass procedures. Surgical management is preferred over medical measures. The procedures include various mid urethral sling procedures like TVT and transobturator tape, sub urethral injections with bulking agents like Teflon, laparoscopic and open colposuspension procedures. Midvaginal sling procedures have high success rates up to 90%. But the transobturator tape has only limited long term data. The efficacy of injections procedures are less than vaginal tapes and may need repeat injections to maintain efficacy. Surgery for SUI should be done only by experienced surgeons with proper training. Anteriorcolporraphy, needle suspensions, paravaginal defect repair and MMK procedure are not recommended by NICE for the treatment for SUI.

Medical treatment with duloxetine less preferred over surgical treatment and should be offered only after counseling regarding the side effects.

Cases resistant to all other modalities should be considered for options like artificial sphinctors.Intravaginal and intraurethral devices can be considered for occasional use such as during physical exercise.
Posted by DR N.
a
a)Other urinary symptoms;freqwency of micturition day or night,nocturia,dysuria,haematuria,hesitancy,poor stream,double voiding and straining to void,nocturial enuresis and bladder pain.
Enquiry about incontinence of faeces and flatus.
Prolaps symptoms,fluid intake,caffeine drinks.
effect on workelife,sport,personal hygiene(having wear apad,duration and progression of symptoms.
Obestetric history;parity with evidence of pelvic floor injury such as third degree tears.
Surgical/gynaecological history;pelvic/incontinence surgery.result of previouse treatment of incontinence,pelvic irradiation.
Medical history and drug thearpy.diabetes mellities,diabetes insipidus,cardiac failure,chronic cough and constipation may worsen stress incontinence.
Neurological disease/symptoms,diuretic therepy.
Reproductive intentions in pre-menapousal women.
Systemic enquiring including mobility and dexterity.
b)General examination including fitness for surgery,mobility and dexterity.exclude abdominopelvic mass and palpable bladder.inspect external grnitalia for ammonical dermatitis.profuse vaginal discharge may mistaken for incontinence.demonstrate stress inconinence,preferably with moderately full bladder.simms speculum examination for uterovaginal prolaps.bimanual examination for pelvic mass and moblity of the anterior vaginal wall.neurological examination,if neurological disease suspected.
c)MSU and dipstix for blood,protein,leukocytes,nitrite and glucose.
Freqwency-volume chart(urinary diary).
Ultrasound assessment of bladder volume.
Multi-channel urodynamics.
d)Choice of operation is dependent weathor is aprimary or repeat procedure,the presence of other pathology such as prolaps,fitness for surgery,moblity of bladder neck.maximal urethral pressure.liklehood of post-operative voiding difficulties,detrusor overactivity,expertise and objective success rate,difficult to compare the efficacy of each procedure as there is no stanerisation of technique,patient population,or length followup;Burch colposuspension/Sling.pubourethral sling,TVT.
anterior colporrhaphy.Needle suspension.Trans-obturator foramen procedures.collagen/macroplastique injections to buttress urethra;each procedure with its faliure rate and complications.








Posted by clarice M.
a) Further details regarding the history of presenting complaint should be obtained. This includes duration of onset, severity of leakage, and other precipitants such as exercise and sexual intercourse. Other urinary symptoms such as frequency of micturition, urgency and urge incontinence may be present and the patient\'s main presenting complaint should be treated first. Red flags such as frank haematuria should prompt an urgent investigation of the urinary tract. Likewise, symptoms of dysuria should prompt a urinalysis and a sample should be sent for microscopy, culture and sensitivity of nitrites are present. A detailed history of the cough and straining should be obtained as appropriate treatment of these symptoms may completely alleviate her incontinence. A sensation of a lump vaginally is suggestive of a pelvic organ prolapse and this can be confirmed on clinical examination. A history of previous continence surgery is relevant as this will influence the treatment options available. For completion, details of her fluid intake should be obtained as cutting down on caffeinated drinks may improve her symptoms. Finally, the impact of her symptoms on her quality of life, both personal, and professionally should be ascertained.

b) The initial examination should include a height and weight to calculate her BMI. Pelvic examination should be performed to identify and grade pelvic organ prolapse if it is present, as well as to confirm the presence of a pelvic mass.

c) A urinalysis should be performed to exclude infection, and a mid-stream urine sample sent for microscopy, culture and sensitivity if nitrites are present. Urodynamics is not indicated prior to starting conservative management but should be requested if surgery is planned.

d) The definitive treatment for urodynamic stress incontinence is surgical. However, for patients who do not wish to have surgery, or have severe symptoms and are awaiting surgery, medical treatment with duloxetine may be an option. It should only be commenced by a urologist or urogynaecologist as it is fairly new drug and long-term data is unavailable. When compared in randomised controlled trials against a placebo, a statistically significant proportion of patients showed a 50% reduction in incontinence episodes. Side effects include gastrointestinal disturbances and vasomotor symptoms. It should be started at the lowest dose and escalated to in a stepwise fashion under the supervision of a urogynaecologist.

A number of surgical techniques for urodynamic stress incontinence have been described. The procedure of choice is a tension free vaginal tape as the patient does not have a cystocoele. This procedure has several advantages, mainly, that it can be done in an outpatient setting and has a 70-80% cure rate at 5 years. Its main disadvantage is that of bladder injury, however the transobturator approach has been described to have a lower incidence of this. Furthermore, there is a risk of mesh erosion with an uncoated tape. A Burch colposuspension may be performed if previous surgery has failed to alleviate the patient\'s symptoms. The open approach is associated with better outcomes compared to laparoscopic techniques. However, Burch colposuspension is associated with an increased incidence of enterocoele formation and the patient should be aware of this. Finally, paraurethral bulking agents can be considered. Although it has a low cure rate, in can be useful in patients who have failed to respond to the surgical procedures mentioned. The patient should be aware that repeated injections are necessary and that the success rate is wanes with time.

Other surgical options such as autologous sling procedures and needle elevation of the bladder neck have fallen out of favour due to low cure rates and serious complications such as osteitis pubis and bladder injury.
Posted by Sowmithya B.
A.Duration and onset, amount of leakage and whether it coincides with the episode of straining has to be enquired. Additional features like urgency, frequency, nocturia, nocturnal enuresis, bladder pain, hematuria and dysuria should be enquired. Voiding difficulties in the form of hesitancy, poor stream, straining at voiding, post micturition dribbling, sensation of incomplete voiding and double voiding should be analysed. Any associated faecal or flatus incontinence should be enquired. Her parity and previous vaginal birth should be noted along with her desire for further child bearing. Previous pelvic irradiation and surgeries including those for incontinence should be enquired. Detailed medical history to exclude condition like diabetes mellitus, respiratory conditions constipation, cardiac failure and neurological diseases should be taken. Detailed drug history should be taken as diuretics, anxiolytics and sedatives can predispose to incontinence. Previous treatments if any should be analysed. The magnitude of the problem has to be assessed and her motivation for treatment should be enquired.
B. General examination as directed by medical history should be carried out for assessment of the predisposing factor. Per abdominal examination should be done to exclude abdomino pelvic mass. Examination of external genitalia to exclude estrogen deficiency, excoriation dermatitis and objective demonstration of stress incontinence in moderately full bladder should be done. Pelvic floor muscle tone and perineal sensation should be checked. Uterovaginal prolapse should be excluded and if present should be assessed. Per vaginal examination should be done to assess pelvic organs and anterior vaginal wall for mobility, diverticulum, scarring and cyst.
C. Mid stream urine examination and dipstick for protein, glucose, blood, leukocytes and nitrites with urinary frequency volume diary for 2-7 days should be done.
D. For urodynamic stress incontinence with failed conservative management duoloxitene 40 mg twice daily can be offered if she has not completed her family. Short term results are good with significant reduction in incontinence episodes with improvement in quality of life in women between 22 and 83 years. Long term results are awaited. The drug is contraindicated during pregnancy.
If completed family more definite treatment should be offered. Beforehand various options with their outcomes (short and long term), benefits and complications should be counselled. As only the first surgery has high chance of cure Burch colposuspension appears to be first line definite surgery with success rate of 85-90% at 1 year and 70% at 5 years. The paravaginal tissue at the bladder neck is fixed to illiopectineal ligament bilaterally. This can be done laparoscopically but long term results are awaited. Complications include voiding dysfunction (10%), detrusor overactivity (15%) and subsequent enterocele and rectocele formation (15%). Transvaginal tape using knitted prolene mesh can also be offered. It can also be performed under local anaesthesia. Success rate is 85-90% at 5 years. Complications include voiding dysfunction (5%), detrusor overactivity (8-10%), increased incidence of bladder injury, intra operative bleeding as the trocher passes through the retropubic space and graft erosion and rejection. Periurethral collagen and macroplastique injection can be offered under cystoscopic guidance. Success rate is 48% and 70% at short and long term respectively. it may need repeated procedures and it is usually offered for fragile and elderly and who are other unfit for major surgery. Transobturator tape can also be offered but long term results are awaited. Anterior repair and endoscopic bladder neck suspension should not be offered in view of poor long term success rate. (20-30%)
Posted by Sarwa H.
A~
We inquire about other symptoms like dysuria, lower abdominal pain, flank pain or fever as urinary tract infection can be the cause behind he incontinence. Also we ask about frequency , urgency and urge incontinence as she nay have also Detrosur over activity. Duration and severity of the condition is explored and whether or not it affect her quality of life as this can help in the diagnosis, selecting most suitable management option and follow up of her situation after treatment. Past medical history is relevant particularly presence of disease like diabetes mellitus or hypertension, also type of medication she take as diuretics can aggravate her symptoms. Also we inquire about other medical disease that can cause ascites and subsequent elevation of intra-abdominal pressure as this can cause incontinence by itself. Past gynaecological history is taken including history of fibroid or ovarian cyst as these can cause pressure over the bladder. Type of contraception she use and her last menstrual cycle is taken as there is possibility of pregnancy, also prolong intake of some contraception like Depo provera medroxy progesterone can cause amenorrhoea due to hypo-estrogeneamia which can lead to vaginal dryness and atrophy. Symptoms like hot flushing and night sweating should be looked for if the patient has amenorrhoea for more than 6 months because she may have premature menopause which can lead to genital atrophy and development of her symptoms. Past obstetrical history is taken. Repeated vaginal delivery can lead to descend of bladder neck below the anatomical plan and cause stress incontinence particularly if her baby is more than 4 Kg. We ask her also if she felt a mass in her vagina as cystocele or uterine prolapse can be the leading cause. I will try to explore the amount of caffeine and water intake per day as over intake can worsen her symptoms. In addition we ask for her wishes about management options and her expectations.

B~
I would look for her BMI because obesity can aggravate the symptoms. I would examine for presence of abdominal mass, distension or ascites. Pelvic examination is done to look for presence of cystocele, uterine prolapse or genital atrophy. Cough impulse test is done to confirm that urine is coming out via urethra upon cough.

C~
MSU analysis with culture and sensitivity test is done to diagnose UTI. Fasting blood sugar is done also to detect undiagnosed diabetes mellitus. Abdominal US can reveal urinary tract pathology, pelvic mass or ascites.

D~
Treatment can be medical or surgical. Medication aim to increase tone of urethral sphincters like α – agonist. It help to avoid risks of surgery and anaesthesia and it can alleviate symptoms. Surgical treatment like Burch Colposuspention can be done, it include elevation of bladder neck back to its anatomical plan, it carries high success rate and low incidence of recurrence. Tension free vaginal tape is also another option, it strengthen urethral sphincter, it carries similar success rate to colposuspention and it can be done under local anaesthesia. Trans-Obturator route can also be employed, it is effective and it carries less risks of urinary bladder injury . Anterior colporhaphy can correct cystocele but no evidence that it helps improving GSI.
Posted by Manoj M.
a) Leaking urine on coughing and straining is urinary stress incontinence symptoms and additional informations on duration of symptoms as embrassing situations might have prevented from seekig early medical attention.
Information about quality of life affected including tactful history of leaking urine with sexual intercourse is important as this will help to decide treatment modalities.
Any associated symptoms of overactive bladder with urgency, frequency is important in management of this patient.
A bladder diary will allow daily fluid intake and to help in differentiating symptoms and helpful to advice on fluid balance.
Any history of previous treatments(conservative/medical/surgical) for same symptoms will help in deciding treatment options.
History of recurrent urinary tract infection(UTI) should beexcluded as may be a possibility of her bladder symptoms.
History of pelvic organ prolapse is important as may need surgical correction along with treatment for stress incontinence.
Specific history in this age group should be on her future fertility wishes as definite surgical options could be deferred untill familiy is completed.
Any history of underlying medical/surgical problems to elicit fitness for future surgical procedures.
History of smear is also important so as not to interfer with any treatment modalities.

b) General physical examination including pulse blood pressure for surgical fitness, body mass index(BMI) is usefull as reducing BMI is helpful in improving quality of life with stress incontinence.
Specific examination of abdomen and pelvis to exclude abdominal pathological masses as contributary factors of blader symptoms, to assess pelvic organ prolapse as may need surgical correction.
To demonstrate urinary stress incontinence as helpfull in substantiating the diagnosis.
Neurological examination to exclude any neurologivcal components of bladder symptoms.

c) Dipstick urine examination for leucocyte, nitrates, blood and mid stream urine if patient is symptomatic of UTI or with dipstick showing nitrates and leucocytes.
Ultrasound of pelvis only if clinical examination is inadequate or to assess residual volume of urine.
Urodynamics is necessary only if undelying mixed symptoms and if contemplating surgical treatment options.
Blood investigation for haemogloin and group as pre assessment for surgery.

d) Treatment options for failed conservative management depends on this patients future fertility wishes as pregnancy after surgical treatment may need repeat surgeries for stress incontinence.
Options also depends on patient wishes and underlying medical conditions of this patient.
Medical option with Duloxetine is helpful if deferring surgery and side effects profile should be explained to the patient.
Surgical treatment options include retropubic mid urethral tape insertion or open colposuspension both have similar sucess rates and failure and but colposuspension is major procedure and currently replaced by retropubic tension free tapes as less invasive and equal sucess rates but long term data is not available.
Intramural bulking agents is alternative option but may need repeat injections and effect may not be long lasting and less effective than retropubic tape procedures.
Artificial sphincter is option for previous failed surgeries but long term followup is required.
Posted by Archna M.
a. A detailed history of onset, duration and severity of symptoms of urinary incontinence is important i.e. to ascertain how much it is affecting her quality of life, for how long and whether increasing in severity?History of any precipitating factors apart from cough and straining like feeling of urge or urge incontinence on putting key in the lock,or with boiling water in cattle.It will help us in evaluating associated OAB.Urgency, urge incontinence ,frequency, dysurea may indicate towards urinary tract infection or mixed incontinence.History regarding quality and quantity of fluid intake is also significant as intake of large amount of fluid or more of caffeinated drinks/alcohol can lead to polyurea which in turn may present as stress incontinence.Medical history of chronic cough, constipation, Diabetes mellitus, cardiac or renal diseases can directly or indirectly due to medication like use of diuretics can lead to UI(urinary incontinence).History of recent onset UI with feeling of heaviness in abdomen or any symptom suggestive of abdomino-pelvic mass(like;Large fibroid uterus or ovarian cyst) can be one of the causes which needs to be ruled out.At the same time it is important to rule out any history suggestive of utero-vaginal prolapse like feeling of \"lump in vagina\",may help in deciding mode of management .History of incomplete micturition or straining on micturition will suggest associated voiding difficulties.It is invaluable to know about any previous medical or surgical intervention for the management of her Incontinence problem.Obstetric history plays very important role as most of the cases antedating with the delivery are due to perineal muscle or nerve injury due to difficult vaginal delivery.History of incontinence to flatus or faeces should not be forgotten.Last but not the least history regarding any pelvic surgery or radiotherapy is also significant to ascertain the cause.Fertility issues should be discussed.
Thus history will help and guide us regarding probable diagnosis,tailoring investigations and deciding treatment.

b.Examination includes assessment of BMI as obesity is one of the important factors in UI.General examination of heart ,lung will help in ruling out any medical problem and its severity ,if history is suggestive.Abdominal examination will be important in ruling out any abdomina-pelvic mass or full bladder or tenderness over bladder.On local perineal examination signs of UI in the form of smell,excoriations may indicate severity of the problem.Per speculum examination will help in determining associated uterovaginal prolapse and its extent by POP-Quantification, If any previous surgery done for the incontinence then mobility of anterior vaginal wall is important in deciding further management.Pelvic examination will help in detecting and adnexal mass.

c.Primary investigation is Mid stream urine test for glucose,protein,nitrites and leukocytes and if it suggests urinary infection then Urine for culture and sensitivity should be send.Patient can be asked to maintain urinary dairy for at least 3 days which includes time, amount and type of fluid intake along with episodes of incontinence both during working and leisure days.If history is suggestive of overflow incontinence or of abdomino-pelvic mass then Ultrasound can be arranged for residual urine or for lump abdomen.USG is not included in primary investigations by NICE. Uroflowmetry of multichannel cystometry are not recommended in initial investigations until unless indicated

d.-For the treatment of Urodynamic stress incontinence when conservative methods have failed then surgery is the option. It is not necessary to do urodynamic investigations in some cases before surgery if clinical assessment suggests pure stress UI. otherwise it is mandatory to rule out associated Detrussor factor and treat it first before contemplating surgical procedure .
Surgical modalities are -1. Retropubic Colposuspension 2.Sling operation using fascia lata or cadaveric graft 3. Retropubic Mid urethral tape like -TVT,TOT,Mid urethral support.
1. Bursch Colposuspension is considered as \"gold standard\"with success rates of 85-90% in 1year and and 75-80% in 5yrs.It has associated risks of Denovo detrussor instability(10%), Voiding difficulties (17%) ,injury to urinary bladder, retension with overflow, risk of Enterocoel etc.and Expertise is needed.
2.Sling Operation using Fascia lata or cadaveric graft also has comparative success rates but it needs to mobilise fascia thus another wound and time taken for recovery.
3. Now a days most popular is mid urethral sling operation using Transvaginal tension free tape(TVT) with \"bottoms up\" or \"upside down\" technique .Results are comparable with Bursch operation with shorter time taken, early recovery and quicker return to work Done under local or regional anaesthesia.Use of Macroporous Polyproplylene mesh is recommended by NICE.Risks are perforation of bladder, denove detrussor instability, voiding difficulties etc.to reduce the risks of urogenital injury TOT i.e. trans-obturator tape has been designed with easier application and lesser risks of injury to Urinary bladder but still some risk will still be there.Mid urethral tape has been designed just to fit below mid urethra ,long term outcomes of these procedures are awaited .Risk of Graft erosion remains.Cystoscopy is recommended before and after the procedure.
Other modalities are - Paraurethral injection of Collagen ,Macroplatique or carbon coated zirconium pellets.-needs repeated injections as effect starts to wean off.It is useful in debilitated patients not fit to stand surgery or in patients with repeated surgery with failure.
Artificial Urethral sphincters- effective but not convenient to use .Applied under G.A.
Urinary bypass-rarely needed in intractable cases
Duloxetin- Serotonin and noradrenaline reuptake inhibitor -not recommended to be used in primary management but if patient refuses surgery or not fit then it can be offered after explaining the side effects of -depression, somnolence ,suicidal tendencies,
Desmoppressin can be used to reduce problems of associated nocturia if present.Propeverin reduces frequency.
Laproscopic Colposuspension, Anterior Colporrhphy, Stamey\'s needle operation ,Parauretharl or paravaginal repair operations or Marshal Marchetti Kranz operations are not advised by NICE.
Posted by Priti T.
prt

a]Detailed History is required to distinguish the symptoms of stess Incontinence[USI] for OAB and mixed incontinence.She should be asked about the duration of the symptoms,urge incontinence or associated nocturia with frequency orincontinence during intercourse;any Hx of bladder pain,haematuria or nocturnal enuresis should be elicited.
Other symptoms of voiding difficulties like poor stream,hesitancy,straining to void or double voiding should be elicited.Any sensation of incomplete emptying of bladder,as well as incontinence of flatus/bowel,constipation should be enquired.Any Hx of weakness/prolapse should be asked.The effect of all these symptoms on the Quality of Life of this young mother is determined
Her personal hx of intake of fluids and caffine/alcolhol is taken.Her Obstetric Hx is to be taken in detail.History of delivering large babies.Whether she has completed her family or she wants more children should be askled as it has bearing on the treatment options.Hx of instrumental deliveries/3rd or 4th degree perineal tears is asked as it weakens the perineal musculature.Past medical hx of Diadetes mellitus,diabetes Inspidus is taken in this otherwise healthy patient.
Any hx of intake of drugs like sedatives,anxiolytics should be noted.Any previous hx of sugical tratment of incontinence should be asked.Her various social circumstances like occupation,access to toilets,lifestyle factors like smoking should be assessed.


b]General physical examination is done.Her BMI is assessed as obesity should be ruled out.Per abdomen examination can reveal palpable bladder and abdominopelvic masses.Vulval inspection is done to detect ammonical dematitis and vaginal dischrge which can be mistaken for incontinence.Patient is asked with full bladder to cough,to detect the urine leakage.Sim\'s speculum examination is done to rule out uterovaginal prolapse;bimanual examination is done to assess the mobility of vaginal wall and pelvic masses.

c]Initial investigations like Urine MSU &dipstix is done for blood,protein,nitrites and leukocytes..Patient is asked to maintain a urine Diary i.e. Frequency Volume Charts for 3 days.USG is done to assess the bladder volume.

d]Patient not responding to the conservative measures should be offered surgical options.Duloxetine is not a primary line of treatment for USI.It is useful in patient who have not completed their family or women awaiting surgery.Long term data for this drug is not available and it has adverse effects like nausea,dry mouth and anorgasmia.
This patient should be offered TVT[tension Free Vaginal Tape].which has success rate of 85-90% in 5 years.This is one of the most common procedure performed in U.K.in recent times;it is a cost effective procedure requiring shorter hospital stay.The disadvantage is the risk of bladder injury about 8%.The long term risk of tape erosion is not known.The other favoured procedure is Burch Colposuspension,which has 80-90% success in 1year and 70% at 5 years.It is associated with various complications like bleeding,urinary tract injury,wound haematomaand denovo bladder instability.Ther can be voiding difficuties in 10% of patients and 1% may require self cathetarisation.There can be enterocele formation.
Laproscopic colposuspention has a lower success rate compered to the above two procedures and requires increased expertise on the part of operating surgeon.There is increased risk of urinary tract injury.
Synthetic slings using retropubic or transobturator foramen approach are the alternative procedures which have a lower success rate .Anterior colporrhaphy is not recommended.Marshall marchetti kantz procedure is also not recommended and acrries the risk of osteitis pubis.
Posted by S M.
a)I would like to know the onset and frequency of the complaints and whether its severity has increased .I will enquire for complaints of dysuria , hematuria and urgency and urinary incontinence during sexual intercourse.I will enquire about recurrent UTI and complaints of urge incontinence.I would like to know about her fluid and caffeine intake , smoking and how much her quality of life is affected by the urinary complaints .I will enquire about associated complaints of constipation, fecal/ flatus incontinence and symptoms suggestive of pelvic organ prolapse. Details of any treatment taken for the same complaints like oral medications and surgeries done will be elicited . I would like to know if she has regular menses and any contraception use.I will enquire about mode of deliveries and for similar complaints in the puerperium .I would ascertain her wishes for future pregnancies.

b) On clinical exam , I will assess her general status and look for depression.I will assess her BMI ,check her respiratory and cardiovascular systems .Her abdominal examination will be done to rule out abdominal-pelvic mass.On perineal exam , I will look for any signs of hypooestrogenism, perineal excoriations , amonnical smell, and any demonstrable urinary incontinence.I would like to assess her perineal sensation and pelvic muscle tone.On per speculum exam , I will look for prolapse.On digital exam ,I will assess urethral mobility and look for uterine size , position and pelvic mass.

c)Initial investigations will include Urine dipstick for protein , glucose , leukocyte and nitrates and mid –stream urine for culture /sensitivity. Pelvic ultrasound for suspicious mass and residual urine will be offered.

d) Her subsequent treatment will depend on her personal wishes.If the patient does not want to have any surgical intervention, or until surgery, Duloxetine may be prescribed.It reduces frequency of incontinence. Side effects of dry mouth , nausea , GI upset , urinary retention, loss of libido must be explained .The drug has to be tapered off gradually to avoid suicidal tendencies.Surgery like Trans vaginal tape ( TVT) and Trans obturator tape ( TOT) may be offered after evaluation by and expert.The advantages are that it is a quick procedure in expert hands and can be done under local anaesthesia.Risk of bladder injury is 8 %.
Burch colposuspencion, a retropubic surgery ,may be offered .It has success rate of 90 % at 1year.Denovo urinary retention and voiding problems may occur .Enterocele and rectocele formation are known side – effects .Needle procedures are not recommended.Marshall Marshetti Kranz procedure causes ostitis pubis, hence not commonly done . Collagen and macroplastique injection in the periuretral area can be tried .Artificial sphincters are used only if previous surgeries fail. Urethral plugs can cause cystitis and vaginitis .
Posted by Mark D.
a-

I will ask the history of associated complaints like frequency, dysuria,urge and hematuria. I will ask if she has a sense of incomplete voiding after micturition.
I will enquire if she has any symptoms of prolapse like something coming out of vagina,dragging lower abdominal pain or incomplete defecation,which may influence the management. I will consider the severity of symptoms and their effect on the quality of life using a QOL questionnaire. I will ask if she has taken any treatments like pelvic floor training or surgeries for these complaints previously.
I will enquire regarding the menstrual history, LMP, current contraceptive usage and future intentions of fertility .I will ask about her past obstetric history – mode of deliveries,any trauma at delivery and any urinary/ fecal incontinence episodes after delivery. I will enquire if she has any precipitating factors for stress incontinence like chronic cough,bronchitis, constipation. I will also check if she has any medical diseases like hypertension, diabetes to assess her fitness for surgical treatment if planned later. I will assess her wishes regarding treatment.

b-

Chest examination will be performed to rule out bronchitis. I willl perform abdominal examination to check for any palpable pelvic mass and a speculum examination to check for any prolapse.if so it should be assessed on POP q scale. I will demomstrate stress incontinence after reducing the prolapse and with a partially filled bladder.
Bonneys test, marshall test and Q tip test are not recomemned in eveluation of SUI. A bimanual pelvic examination will be done to rule out any pelvic masses like fibroid uterus or adnexal mass which may press on the bladder and lead to incontinence.

c-

I will ask the patient to maintain the bladder diary over the next 3 working and leisure days. I will send the sample of urine for routine and microscopic examination to check for sugar,proteins, leucocytes and nitrites and rule out hematuria.I will check post void urine.Ultrasound is preferred over catheterization for this ,if available. Conservative management can be started before urodynamic study.
Urodynamic evaluation is required in patients with mixed incontinence and where previous surgeries for SUI have failed. If hematuria is present the cystoscopy should be done to rule out growth or ulcers in bladder.

d-

The patient should be counseled regarding risks and benefits of various surgical and nonsurgical options and written information provided.
Retropubic midurethrl sling procedure with ’bottom up’ approach using macroporous polypropelyne mesh , open colposuspension and rectus fascial sling all provide 85% continence rate at 1 yr and about 75% continence rate at 5 yrs of follow up. They should be used as a first line tratements.
TVT can be done under local or regional anesthesia, is a daycare surgery, and tension on the tape can be assessed on the table. It has advantage of early return to normal activities ,avoids wound morbidity,and gives quick recovery. However it has a 9% urethral injury rate ,and is associated with post of voiding difficulties with 2% requiring long term self catheterization. Vaginal mesh erosion is also reported.
Open colposuspension is the most evaluated method with best long term continence rates. However it has 13% risk of post operative posterior compartment prolapse, 17%voiding difficulties and 14% getting de novo detrussor instability. Abdominal incision increases hospital stay ,immobility,increased risk of thrombosis and wound morbidity.
Anterior colporraphy , paravaginal repair, suspension procedures and laproscopic colposuspension is not recomended due to high failure rates. MMK gives similar continence rates but has a characteristic complication of osteitis pubis in 2.5% cases which is difficult to treat.
Para urethral injections with silicon or collagen can be considered in cases of previous failed surgery.they give a continence rate of 60%.Their efficacy decreases with time and hence repeat injections may be needed.
Patients with previous failed surgery may consider artificial sphincter implantation. It gives continence rates of 75-80% but may need repeat surgery for device malfunction in 15% of cases within 2 years.
Duloxetene should not be used as first line treatment .It may be considered in patient who have declined surgery after counseling about the adverse effects like Gi upset,headache ,loss of libido and visual disturbances.

Posted by syeda sajida M.
urinary incontinence is a medical as well as a social problem. Woman feels embarrassment and it effects her quality of life. I would like to know in her history about the duration of onset of symptoms whether recent or started few years ago. How much these symptoms affecting her quality of life. If she is using some sanitary protection , towels, pads or change her underwear frequently. This will give me an idea of severity of her condition. I would like to know about her obstetric history when she delivered her last baby and whether her deliveries were normal vaginal deliveries or instrumental.Whether she had prolonged labour and if she had 3rd. or 4th. degree perineal tears. I would like to know her medical history if she is suffering from any medical condition like hypertension, diabetes or taking any medication like diuretics or psychotropics drugs. I would ask her if she has been suffering from chronic constipation or chronic chest problem such as asthma, chronic cough. Her history of previous treatment of urinary incontinence is very important for further management. I would like to know if she has urinary leakage during sexual intercourse, or if she is suffering from enuresis, nocturia, urge incontinence. If there is difficulty in passing urine or burning micturation or has she seen blood in her urine which indicates urinary tract infection.
B. On clinical examination I would like to know her weight and BMI. Her chest examination is important if there is positive history of respiratory disease.I will palpate her abdomen to exclude any abdominal mass.On speculum examination I will look for cystocoele rectocoele or uterine prolapse and objective assessment for urinary incontinence. On vaginal examination, I would like to assess her uterine position and size and adnexal mass.
C. I would ask her to maintain her frequency volume chart for three days to assess her bladder function and habit. I would do the urinary dipstick for presence of blood or proteins in urine. In case of positive findings I would send mid stream urine sample for culture and sensitivity. Pelvic ultrasound which is a non invasive test can give information regarding residual urine and uterine fibroid.
D. Duloxetine, which is a serotinine and nor adrenaline re uptake inhibitor is not a primary treatment for urodynamic stress incontinence . It is useful only for those patients who refuse surgical treatment. Prior to any surgical treatment it is recommended to do urodynamic investigations.Among retropubic procedures Burchcolpo suspension still considered to be the gold standard primary procedure with one year success rate of 85-90% and after 5 years 70%. Complication associated with this procedure are Denovo detrusor instability in 5-18 %, 18% develop cystocoele or rectocele. Post operative voiding difficulties in 10%. It can be performed laproscopically which is less invasive but 20% less successful and 15% failure rate. Among sling procedures tension free vaginal tape(TVT) is technique where specifically designed prolene tape is used to elevate the bladder neck. It can be performed as a day procedure. 1 year success rate similar to burch colposuspension but long term follow up data is limited. Complications are vaginal erosion, urethral erosion, detrusor overacvtivity, intraoperative bladder perforation. New technique of transobturator foramen procedure (TOT) with one year suucess rate similar to TVT but still under evaluation.
Other less frequently used procedures are marshall marchetti krantz procedure where bladder neck is supported from periostium. Its complication is osteitis pubis. Anterior repair is less successful for urinary incontinence with one year success rate is 63%which reduces to 37% at 5 years. Needle suspension procedure should not be performed as there initial success rate is not maintained with time and high failure rate. Injectable paraurethral bulking agents like fat, collagon have low success rate then other procedure but with low morbidity. They are useful when other procedures have failed. Artificial sphincters can be used in case of previous failed continence surgery but it is associated with high morbidity and repeated surgeries.

Posted by Arun J.
a_ Appropriate history includes enquiering about urinary symptoms(like presence of frequency in day & night,dysuria ,haematuria, nocturia, nocturnal enuresis,urgency ,urge incontinence,their duration any treatment taken before and their outcomes,bowel symptoms(urgency incontinence of feces and flatus) & sexual symptoms(sexual incontinence,dyspareunia, a quick review of her records,and other histories such as H/O massdescending P/V iits duration, & history to R/O chest ,cardiac, and neurologic diseases,& personel history to ask about smoking alcohol intake and use of recreational drugs, fluid intake, diuretic usage and finally enquire about menstrual cycles ,LMP & obstetric history(modeof delivery and any obstetric injury to anal sphincter if any).
b-General exam done to R/O respiratory,cardiac, abdominal, and neurological diseases.Local exam done to assess estrogen status,excoriations,prolapse of uterus, scars of previous surgeries, mobility of paravaginal tissues, and Bonneys test is also done.
c_investigations include Urine routine,MSU - C&S,baseline RFT,USS and subtracted cystometry.
d_Surgical options are tried after failure of conservative treatement.Burch colposuspension is effective with a cure rate of 80-90 %,useful as a primary as well as secondary procedure,except that its morbidity is more because of abdominal procedure.TVT has similar efficacy as the previous one but since it is a retropubic procedure it needs additional cystoscopic evaluation & risk of haemorrhage is more.TVT-O is an effective office procedure with similar efficacy as burch, used as primary & secondary procedure though longterm data on outcome are not available.Needle suspension procedures are less efficacious with more complications.periurethral injections are useful in those who are not fit for surgery and longterm continence rate is also less. Artificial sphincters used for patients who failed multiple attempts at surgery but it is costly and the risk of device malfunction is there.
Posted by J P.
a.I will take a detailed history regarding duration ,severity of symptoms and the quality of life affected due to these symptoms.Other symptoms like frequency,urgency and urge incontinence suggestive of over active bladder syndrome will also be enquired. Pain on voiding suggestive of UTI and hesistancy,poor stream suggestive of outflow obstruction will also be enquired.Nocturia,bed wetting,use of incontinence pads and toilet mapping will be asked.Any mass in abdomen suggestive of fibroid and history suggestive of prolapsed will be enquired.Her fluid intake,caffeine and alcohol intake which may predispose to urgency ,if present,will be enquired.Previous incontinence surgeries if done any and her wishes for treatment will be enquired.
b.This will include general examination for BMI and blood pressure for planning the management.Speculum examination will be done to rule out the presence of any prolapsed.Bimanual pelvic examination to be done for the presence of any abdominal pelvic mass.
c. Initial investigation include MSU,dipstixfor protein,blood[UTI],nitrites and glucose.Frequency volume chart to be maintained to assess the severity of the condition.USS pelvis will be done to detect urinary residual volume.Urodynamic study will be done if there are mixed symptoms or symptoms not responding to conservstive management.Cystoscopy is indicated if there is persistent hematuria.
d.Further treatment options may be surgical or medical.Open Burch colposuspension remains the first line surgical management.This elevates the paravaginal tissue to the ipsilateral illiopectineal ligament and has a continence rate of 80-90%in 1 year and 70% in 5 years.Complications include voiding dysfunction,denovo detrusor instability[10%],long term self catheterization,development of enterocele[10%],operative morbidity. Laproscopic colposuspension do not have similar success rates due to less number of sutures used and depends on surgeon skill.This is costly but has the advantage of less post operative morbidity and hospital stay.
Sling procedures like TVT which support the mid urehtra can be done under local anaesthesia.Success rate is 70-80% in 1 year but long term trials are awaited.Complications include bladder injury,detrusor instability,voiding dysfunction,tape erosion.Long term success rates for TOT procedure are awaited.Marchelli-Marchetti-Krantz procedure not widely used due to risk of osteitis pubis.Needle suspension procedures not done as first line surgical treatment due to morbidity.Anterior colporraphy with bladder neck buttressing has a low success rate.Intramural bulking agents like collagen,glutaraldehyde have lower success rates,higher morbidity and can be used in failed cases.
Medical management with duloxetine [SSNRI] at a dose of 40 mg/day can be given if unfit or surgey is declined.Side effects include gastro intestinal disturbance,headache,nausea and anorgasmia.

Posted by A S.
Am

a- Taking history is very important because it will categorize patients regarding types of urinary incontinence . This is best established by giving the patient a 3 days bladder diary to be completed before her clinic appointment .This will include data about fluid intake ,frequency of going to the toilet, amount voided ,associated symptoms like pain and urgency . It will also reflect the impact of her complaint on quality of life , her daily activities and personal relations .
We will then discuss her complaint details and ask about timing and details of her deliveries if normal or operative vaginal or by cs and whether associated with complications or no. History of previous treatment for incontinence medical or surgical ,previous pelvic surgery, , pelvic irradiation ,, flatus and fecal continence will influence therapy. Personal history of diabetis m or multiple sclerosis should be excluded .Constipation and chronic cough are relevant complaints.

b- General examination must include body weight and BMI. Abdominal examination for masses and inguinal lymph nodes . Pelvic examination for prolapse , vaginal hygiene and infections ,pelvic masses and integrity of pelvic floor muscles should be done .

c- Mid stream urine sample will be tested for glucose ,nitrite , RBCs and leucocytes . If nitrite is positive then culture and sensitivity will be ordered. I f heamaturia is present referral will be adviced .

d- Treatment for urodynamic stress incontinence is initially conservative in the form of pelvic floor muscle training lasting three months . 8 to 12 contractions are repeated 3 times daily . Success rates are good but relapse is common if exercises are stopped .
If PFMT didn t improve her symptoms the second line will be surgical after exclusion of urge or mixed incontinence . Retropupic mid urethral tape procedures using macroporous proline mesh has similar success rates to open colposuspension 80 % to 90 % after 1 year and 75 % after 5 years . Rates of complication depends on the experience of the operator . Bladder perforation in tape procedures occurs in 9% compared to 2% in open colposuspension but with less bleeding and shorter hospital stay . Mid urethral tape procedures can be done transobturator but long term results are unclear. Needle suspension is not recommended because of high failure rate 85% after 1 year . Anterior colpoperineoraphy and Marshal Marchetie operations are not recommended because the newer procedures give better results and ostitis pubis occurs in the later .
Doluxitine is not given except in women declining or unfit for surgery. It is a serotonine noradrenaline reuptake inhibitor . Its main side effect is nausea .
Intra mural urethral bulking agents as macroplastique , collagen and silicone are used in cases of intrinsic sphincter deficiency. They give only short tem good results but may migrate , need repeated injections and need long follow up.
Artificial sphincters are only used if other procedures failed.

Posted by Neelam A.
A. A detailed history should be obtained regarding duration, severity, frequency, regular use of sanitary towels and the impact of this problem on her quality of life. Other urinary symptoms such as urgency, urge incontinence, haematuria, voiding problems, urinary infection and overactive bladder symptoms in form of frequency nocturia etc should also be asked to classify type of incontinence. Symptoms of faecal incontinence should also be reported.
Precipitating factors which predispose to increased intra-abdominal pressure such as chronic cough including history of smoking, constipation and obesity should also be inquired.
It is a good idea to know drinking habits- use of caeffine, alcohol and diuretics.
Obstetric history is also important to know – number of previous pregnancies, duration of labour, instrumental delivery and big sized babies as all these predispose to damage to urogenital system. An enquiry should also be made regarding future fertility plans.
A history of abdomino-pelvic masses such as big fibroids, ovarian lumps which may cause leakage because of the pressure effect in addition to prolapse symptoms should also be obtained.
In surgical history it is important to know any past history of any abdominal or pelvic surgery resulting ureter or bladder damage including use of radiotherapy which would influence future surgery.
Any past history of any surgery for incontinence or conservative measures taken should also be documented.

B. General examination should include height and weight to calculate the body mass index (BMI). Lungs should be auscultated to rule out chronic chest problem.
Abdominal examination should be done to palpate abdominal or pelvis masses or bladder.
Local examination should be done to assess leakage on coughing in case of stress incontinence or triple swabs test to know site of fistula.
Speculum examination should be done to see degree of prolapse in cases of prolapse symptoms.
Bimanual examination should also be done to palpate pelvic masses.
An Oxford scoring assessment should also be done to know the tone of pelvic floor.

C. I would test urine dipstix and urine culture sensitivity if she is symptomatic or positive nitrate or leucocytes on dipstix.
A bladder scan should be organized if palpable bladder or positive history of voiding problems or chronic repeated urinary infections.
She should also be asked to keep volume frequency diary to assess degree and type of incontinence.
Abdominal or pelvic scans should be organized if there is any doubt about them.


D. Before attempting any surgery, she should be asked about her desire of fertility. Surgery should be delayed until she has completed her family.
Retropubic mid-urethral polypropylene tape is the surgery of choice. Success rate is operator dependant approximately 95%. Long term data is not available. She should be warned of the complications in form of voiding difficulty (6%), damage to bladder, reactions to tape and detrussor overactivity. Advantages are short operating time, quick recovery, short hospital stay, can be done under local.
Transobturator tape is the other preferred surgical procedure for stress incontinence. Bladder injuries are less likely with this procedure compared to mid-urethral tape. Long term data are not available.
Burch open colposuspension has been practiced since long time. Long term data are available. Success rates are 95%. Complications are bone necrosis, voiding difficulty and detrussor overactivity. It can be done laparoscopically but success rates are poorer than open surgery. Therefore it is not recommended routinely by NICE guideline.
Autologous rectus fascial sling is other available option.
Intramural injections of bulking material such as glutaraldehyde, silicon and collagen can be given in women who are at high risk for anaesthesia or surgery. However they should be aware of need of repeated injections, reduced efficacy with time and poor outcome compare to retropubic sling or suspension.
Artificial sphinctors are last but not the least available surgical procedure for this condition. These women need regular long term follow up after this surgery.
Other surgical options are Marshall Marchetti Kranz procedure, needle suspension, anterior repair are not recommended by NICE either.
Posted by H H.
A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks]
I would ask the patient if she has other urinary symptoms ,urgency,urgency incontinence or nocturnal enuresis which may point to associated detrusor overactivity, dysuria or hematuria which may be due to associated urinary infection.I will ask of associated incontinence to faeces or gas. I would go through her obstetric history and difficulties encountered, past gynecological history including presence of vaginal wall prolapse, fibroids and wether vaginal operations were done to her, past medical history including chest problems, constipation, and any previous medical treatments given for her condition. I would ask her of the effect of her symptom on her quality of life, her fluid intake including coffee and alcohol . I would ask her of her smoking habits and her life style wether it includes excercises like squash where her symptom might be distressing.
(b) What information would you obtain from the clinical examination [2 marks]
Iwould measure BP , her BMI ,do chest examination for chest problems,and abdominal examination for abdominal masses.I would look for ammonical dermatitis in vulval region and perinea area. I would ask her to strain and see if associated cytokine,and ask her to cough to demonstrate her symptom but this is not always demonstrable . I will do local exam to feel mobility , position and size of uterus.I would feel mobility of urethera and do Bonney test
c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks]
I would do MSU to exclude infection, do urine dipstiks exam for proteins, nitrates which denote infection, glucose which may denote diabetes mellitus, and blood which denote hematuria needing further investigations like cystoscopy. I would do urinary diary to measure aount and frequency of voided urine to tell me an idea about urinary capacity.Urodynamic studies are not done at this stage.

d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence. Evaluate the subsequent treatment options [6 marks].
Medical treatment with Dolexetine should not be first choice after failed conservative treatment due to frequent side effects(nausea and vomiting) ,but could be used if patient does not want to have surgery.It is an effective treatment as it act on uretheral sphincter making it more continent( An SSNRI inhibiting the reuptake of serotonin and nor epinephrine)
Tension free vaginal tape TVT is taking over Burch colposuspension as a surgical procedure for treatment of GSI, being simpler, can be done under local anaesthesia in a day case surgery, less operative and postoperative complications , cost effective and at same time gives same results with continence rate in 80% of patients over 5 years.TVT secure can be used and is less invasive than TVT. Transobturator tape is being used and results are awaited. It has the advantage over TVT in that there would be no injury to the urinary bladder and so cystoscopy is not needed to check while being applied.Burch colposuspension can be done laparoscopic ally but resuts are less.
In patients who are surgical risk parauretheral injection of synthetic material can be effective but long term results are low and need further injection.
Older procedures ,like Kelleys suture or Stamey needle procedures have low cure rate and fell out of use.
The use of mechanical methods to close the urethera might be a temporary method in situations like playing squash in patients who decline surgery
Posted by M M.
A) The duration and severity of her symptoms and the impact on her daily life should be enquired. Other urinary symptoms such as urgency, frequency and urge incontinence should be asked as many women may have mixed incontinence. Symptoms of dysuria or haematuria may suggest urinary tract infection or other more sinister causes. Obstetric history should be explored and any previous difficult vaginal deliveries especially with macrosomic babies noted . History of chronic cough or constipation should also be identifiend. Other co-morbidities should be enquired to assess patient\'s fitness for surgery. Past surgical history should be enquired especially any previous continence surgery done. Finally the woman\'s desire for treatment and whether she has completed her family should be enquired.

B) The weight and height should be noted to assess her BMI. Presence of any abdominal or pelvic mass should be noted. Pelvic examination should be carried out to assess for uterovaginal prolapse if present. Stress incontinence may be demonstrable with cough test.

C) Initial investigations include urine analysis and culture to exclude urinary tract infection. The woman should be asked to use frequency-volume chart and urinary diary.

D) Duloxetine which is a serotonin and noradrenaline reuptake inhibitor may be offered when conservative treatment fails and the woman prefers pharmacological to surgical treatment or not suitable for surgical treatment. It has been shown to be effective to reduce incontinence episodes and improve quality of life. However long term data is unavailable. Use of duloxetine are associated with side effects such as headaches, nausea, GI disturbance, reduced libido and also withdrawal reaction.
Burch colposuspension is the most effective surgical treatment for stress incontinence. It has high continence rate at 1 and 5 years. It may be done laparoscopically or open. Open colposuspension may be more successful compared to laparoscopic approach. Complications include de novo detrusor overactivity, voiding disfunction and posterior vaginal wall prolapse.
Sling procedures using autologous or synthetic materials produce success rates of simmilar to colposuspension at 5 years. TVT may be performed under local anaesthesia or as day case. It is suitable for woman who has had previous colposuspension or in cases with low urethral pressure. It is associated with de novo detrusor overactivity, voiding dysfunction, bladder perforation, intra-operative bleeding and erosion of sling long term. Trans obturator foramen approach may be used to avoid risk of bladder injury. However long term data is not available.
Other options include injectable agents administered at periurethral tissue or bladder neck. It is associated with low morbidity but the success rate is low and the effect declines with time.
Artificial sphincter may be used in failed surgery but it is associated with high morbidity and re-operation rates.
Posted by Atashi S.
( a ) History should be taken regarding the severity of symptoms and its effect on quality of life. Her mode of delivery should be asked for including history of difficult vaginal delivery or instrumental vaginal delivery. Any history of perineal injury should be looked for. Whether the symptom follows from child birth or developed thereafter. History of excessive fluid and caffeine intake should be taken. H/O recurrent UTI, presence of haematuria or continuous leakage of urine should be taken. Presence of urge symptom should be asked for. Presence of chronic constipation should be looked for.
( b ) Abdomino pelvic examination is to be done to exclude any abdomino pelvic mass. Vaginal examination is to be done to detect presence of any degree of urogenital prolapse .Voluntary pelvic floor muscle contraction and
perineal sensation should be assessed.
( c ) Mid stream specimen of urine should be tested for presence of leukocyte ,blood, sugar or nitrate and culture & sensitivity if indicated. Frequency and volume chart and urinary diary should be maintained. Pelvic ultrasonography is to be done to detect any lower abdominal mass.
(d ) After failed conservative treatment she should be counselled for surgical treatment regarding effectiveness and complication of various procedure. Choice of operation is dependent on presence of other pathology such as prolapse, fitness for surgery, mobility of bladder neck, maximum urethral closure pressure, likelihood post operative voiding difficulty or detrusor overactivity, surgical expertise and objective success rate. Retro pubic procedure-Burch colposuspention associated with continent rates of 85% to 90% at 1 year And 70% at 5 years. Operation shows better longevity than other procedure and has similar short term continence rates to suburethral sling procedure .Increase risk of failure in patient with low urethral resistance. Risk of denovo detrosor over activity 17%(8-27%), voiding dysfunction 10%(2-27%), enterocole or rectocole formation 14%(3-27%) after 5 years.
Retropubic procedure have better outcome compare to anterior repair 11% and 24% failure rates respectively at one year. Benefit of colposuspansion is maintain for 5 years while that of anterior repair diminishes rapidly 25% and 69% failure rates respectively at 5 years.
Sling procedure : Pubo urethral sling, tension free vaginal tape.
Suitable in case of low urethral pressure . Success rates of 85-90% at 5 years(No long term data is available for TVT). 86% of objective cure rates at 3 years, 8% risk of bladder injury. Risk of denovo detrosar over activity 3-15%, risk of voiding dysfunction 4.3%. Errosion of sling may occur several years after surgery. Anterior colporrhaphy-poor success rates, continent rates of 66% at one year, 37% at 5 years. Needle suspension associated with low perioperative complication but poor long term outcome only18% at 5years. Other surgical procedure-collagen or micro plastic injection low success rate 48% continence with 76% improvement in short term which decline with time. Selected in woman with intrinsic sphincter deficiency.
Posted by Joshimin F.
A.
Her symptoms of urinary leakage on coughing and straining are suggestive of urinary stress incontinence. The severity and duration of symptoms should be enquired. The impact of symptoms on quality of life should also be asked. Her fertility wish and desire for treatment should also be asked. Her sexual function and her expectation should also be considered. Other symptoms such as urgency, frequency suggestive of urge incontinence should also be noted. Symptoms of urinary tract infection such as burning sensation, dysuria, frequency should also be asked. History of delivering large babies followed by instrumental vaginal delivery may have an impact to her symptoms. History of constipation, chronic obstructive lung disease may aggravate her symptoms. Other medical problems such as diabetes should also need to be explored. Her medication also need to be reviewed and may be associated with urinary incontinence including sedatives, diuretics. Previous continence surgery may influence her management. Social circumstances need to be consider including home environment, personal relationship, occupational history and life style factors such as smoking need to be enquired.

B.
Abdominal examination should be performed to rule out any pelvic mass or palpable bladder. Pelvic examination need to be done to assess uterovaginal prolapse.

C.
She should complete voiding diary at least 3 days covering variation in usual activities. Urine dipstick test need to be done to detect presence of blood, glucose, protein, leucocytes, nitrates. If leucocytes and nitrates detected, mid stream urine should be send for culture and sensitivity.

D.
Surgical management is another option if conservative management failed to improve her symptoms. Choice of operation dependent on the presence of prolapse, surgical expertise and her wishes particularly with respect to the risk of long term voiding dysfunction. Retropubic mid urethral tape procedures such as tension free vaginal tape is recommended for her. Tension free vaginal tape has 80-90% efficacy, and can be performed as day care procedure with faster recovery. However, tension free vaginal tape has risk of bladder perforation, mesh erotion, infection, denovo detrusor instability, and voiding difficulty. Burch colposuspension is another alternative and has 80-90 % success rate at 1 year but it has complication of urinary tract injury, wound haematoma, denovo detrusor instability, enterocele formation and voiding dysfunction. Synthetic slings using transobturator foramen approach is recommended as alternative options however she should be made aware of the lack of long term outcome data. Intramural bulking agent using silicone, collagen has lower efficacy compare to that of retropubic suspension or sling. She should be explained that repeated injection may be required to achieve efficacy and efficacy diminishes with time. She should be given information leaflet regarding her treatment option to allow her to make informed consent.
Posted by sara S.
(a): Further informations in this case will be asking about daily intake of fluids, amount of tea & cofee and number of times emptying bladder in the mor ning or at night. Type of incontinence will be inquired, whether urge or stress or mixed incontinence. History of medical codition which result in increase in abdominal pressure such as constipation or chronic cough. Any probelm with nervous systems affecting nerve supply such as Multiple sclerois. Details of medication such as diuretics. Severity of symptoms asked which affect the quality of life & need for use of incontinence pads. Other symptoms of dysuria, interrupted stream, and incomplete emptying. Obstetrical history is obtained , number of children & mode & complexity of deliveries. Any previous pelvic surgery,pelvic irradiation or surgery for incontinence. Family history of diabetes will be asked.
(b) Abdominal examination may demonstrate a fibroid which may be cause of leaking due to pressure. Vaginal examination show the presence of ant wall prolapse if any or uterovaginal prolapse. Stress incontinence may be demonstrated while asking the patient to cough. Laxity of vaginal wall and power of contraction for vaginal wall is checked.
(c) Mid stream urine is sent for Culture & sensitivity to rule out infection. Patient is refered for urodynamics.for confirmation of diagnosis of GSI.Blood glucose levels are checked to rule out diabettes
(d) Further options are commencing her on SNRI sush as Duloxetine if there is no contraindication such as pregnancy or epilepsy,Side effects such as GI upset and headache.Medical treatment is not first line , it may be considered if patient is not fit for surgery or prefer pharmacological treatment.,Mechinical devices may be cosdered. In surgical Colposuspension ,TVT and TVT-O are discussed. There long term results and complication are explained . Burch Colposuspension has complications of de novo detruser instability, voiding disorders & rectocoele & enterocoele. TVT has potential complication of mesh erosion, infection and de novo detrusor instability.
Posted by Sowmithya B.
Sir,
Kindly clarify my query? Can a women who has not completed her family be offered definitive sugery for stress incontinence?
thanks.
Posted by Sowmithya B.
Sir,
Kindly clarify my query? Can a women who has not completed her family be offered definitive sugery for stress incontinence?
thanks.
Posted by G. K.
a thorough history should be obtained in elation to the duration and severity of symptoms. Ask if the problem is effecting her quality of life in any way.Inquire about the use of continence pads.Inquire about associated problems such as urgency, nocturia to rule out the possibility detrusor overactivity.Inquire about dysuria, frequency and hesitancy to rule out the posibility of UTI.
Take a detailed medical history to rule out any respiratory prblem leading to persistent coughing since it can make her problem worse.Also inquire about bowel habits to rule out constipation.
Personal history regarding smoking and alcohol intake should be looked into.Inquire about her daily fluid intake in terms of tea, coffee, and fizzy drinks since excess of these can make her problem worse.
As we know her parity, establish whether these were normal deliveries or caesarian sections since vaginal deliveries deliveries tend to weaken the pelvic floor.
Clinical examination should entail noting the BMI since a high BMI makes stress incontinence worse.
Vaginal examination should include resting pelvic tone, the ability of the patient to carry out a pelvic contraction. During the examination, the patient should be asked to cough to see if there is any leakage of urine. A per rectal examination should assess anal tone and note the presence of any hard stools.The presence of a cystocele or a rectocele should be noticed.
Initial investigations include, urinlysis to rule out UTI, ramdon blood sugar to rule out diabetes mellitis and urodynamic investigations to establish the diagnosis.
If conservative Mx fails, the other options remaining are surgical and non surgical. surgical options are colpsuspension which is considered as the gold standard. Other options include TVT or TOT.Colposuspension has a high sucess rateof 90% at 1 year and 80 % at five years. It is associated with denovo detrusor instability , voiding difficulty.with TVT andTOT have similar sucess rates.Although they have problems associated with mesh insertion such as erosion, infection, bladder and urethral damage.
If surgery is not an option than other treatment options include external meatus plugs, urethral plugs etc.they have a high sucess rate but are associated with complications such as infection, cuff erosion, damage to urethra.
Posted by Seema  B.
HISTORY
a)Urinary incontinence is a common problem which can affect a woman, both, socially and psychologically affecting her quality of life.
Urinary Incontinence maybe due to various causes and value of a detailed history cannot be overlooked. Ask regarding any associated symptoms although difficult to make diagnosis on symptoms alone.
Urodynamic stress incontinence is classically associated with involuntary leakage on effort or on coughing and straining as this woman presented.
Detrusor overactivity is classically associated with frequency, urgency, urge incontinence, nocturia and nocturnal enuresis.
Continuous dribbling or post micturition dribbling are more likely to be associated with neurological disorders, overflow, urethral diverticula or a fistula.
Ask regarding symptoms of urinary tract infection like frequency, dysuria or haematuria. Bladder pain may suggest interstitial cystitis.
Precipitating conditions for urodynamic stress incontinence like chronic cough and constipation should be enquired.
Ask regarding fluid and caffeine intake.
Note her parity and previous pregnancy outcomes and her desires regarding future fertility.
Is she using any contraception as oral contraceptive pills may need to be discontinued 6 weeks prior to any major surgery. History of any chronic medical illnesses is also taken to assess her suitability for anaesthesia and any major surgery.
Enquiry should be made regarding any voiding dysfunction as some surgical procedures may aggravate any pre-existing voiding dysfunction. Ask about associated faecal incontinence.
Finally, ask regarding severity of symptoms, the presence of prolapse and previous surgeries if any, and the effect of previous treatments.This will help in deciding the most appropriate treatment option. Woman\'s wishes and choice should be taken into consideration.
Written information and contact details of support groups should be provided.

CLINICAL EXAMINATION
b) I will assess her body mass index from height and weight.
Objective confirmation of involuntary leakage of urine per urethra or coughing and straining is made. Look for the presence and severity of any associated prolapse.
A fistula, if large, may be seen on speculum examination.

INVESTIGATION
c) I will ask the woman to complete a bladder diary to quantify urinary frequency and incontinence episodes. She is asked to complete a 3 day period to allow variation in day-to-day activity such as, both, working and leisure days.
Urine dipstick tests to detect blood, glucose, protein leucocytes and nitrites is done.
Multichannel filling and voiding cystometry, ambulatory urodynamics and videourodynamics are recommended before surgical treatment.

EVALUATION TREATMENT OPTIONS
d) Treatment can be pharmacological or surgical. The most appropriate treatment option would depend on the the severity of symptoms. The presence of prolapse, previous surgery, mobility of bladder neck, likelihood of voiding dysfunction, suitability for major surgery and available surgical expertise. The womans child bearing wishes should be considered.
Duloxtine, a selective serotonin and noradrenaline re-uptake inhibitor is associated with a significant reduction in incontinence episodes and improvement in quality of life. It is associated with dry mouth decreased libido and anorgasmia as major side-effects. It is associated with withdrawal reaction and hence, dose should be gradually tapered over a 2 week period. Long term data on duloxetine is not available. It should not routinely be used as a first or second line treatment for stress urinary incontinence. Maybe offered as an alternative to surgical treatment. The woman should be counselled about adverse effects.
The first operative procedure offers the best chance of cure, therefore, select the most appropriate procedure for each patient. As a primary procedure, Burch colposuspension remains the gold standard for surgical treatment with success rate of 80-90% for first year. Open colposuspension is more successful than laparoscopic procedure. It is associated with 10-12% risk of voiding dysfunction. There is also increased incidence of destrusor overreactivity and enterocele and rectocele formation. Surgical expertise is widely available.
Laparoscopic colposuspension has lower success rate with increased risk of urinary tract injury and expertise is not widely available.
The Marshall-Marchetti Krantz procedure has similar short term success rate to the Burch colposuspension but carries the risk of ostetis pubis which is diffcult to treat.
Sling procedures such as stamey operation have poor long term success rate but also low morbidity.
The tension free vaginal tape (TVT) is just as effective as Burch colposuspension after 1 and 5 years. There is 8% risk of bladder injury. Long term risk of tape erosion is not known. Has shorter hospital stay compared to colposuspension .Prolapse surgery may be undertaken concomitantly. Ideal for women with poor anaesthetic/surgical risk profile.
Transobturator is a new procedure with similar success rate to TVT. Long term outcome data not available.
Anterior colporrhaphy with bladder neck buttress has low complication rate but long term cure rate is also low.
For surgery after previously failed procedure-TVT is suitable after failed colposuspension .
Other procedures include collagen injection, artificial sphincters, neourethras and urinary diversion. They should be reserved for expert surgeons and intractable incontinence.
Posted by Ahmad A.
I would like to have a detailed history of her previous difficult deliveries, or using forceps specially midcavity. Also, I would ask for any vaginal tears especially of third or fourth degree tears may cause faecal incontinence with urinary incontinence. Also, if there is any anterior vaginal tears and/or urethral lacerations. I would ask about the duration of her symptoms and if there is direct relation between the deliveries or not, also the dates of her birth specially with recent delivery. Also, if it recur with subsequent delivery. I would ask about her general habits of smoking, alcohol, fluids and coffee taking. I would ask about the other symptoms of possible urinary tract infection (UTI) like frequency or burning micturition and other symptoms of detrusor overactivity like urge incontninence, nocturi, frequency. I would ask if these symptoms affecting her social life or if she in need for extra precautions during social events or her regular exercise.

Clinical examination should tell us about the abdominal examination of possible palpable masses. Also, the local examination of vulval irritation because of longstanding leaking and possible vulval or vaginal ulcerations. Pelvic examination of pelvic area using sims and or standing position with evaluation of the degree of anterior or posterior vaginal wall prolapse.

Urine sample, microscobical and midstream for culture and sensitivity should be asked initially to rule out UTI. Also, I would recommend to have Flowcystometry to rule out other possible problem like over activity and to confirm urodynamic stress incontinence (USI).

The possible treatment option in case of failure of the conservative management either medical or surgical. Medical treatment like using Detrusitol as, it may improve the condition by 50-60%. On the other hand the surgical procedure may be offered in case of failure of other options. There are many surgical procedures could be offered. However, with healthy woman, the best 2 options either colposuspension or sling procedures. Burch coposuspension is one of the successful procedure may give up to85-90% continent rat after 3-5 years. Also, it may help correction of the anterior vaginal wall prolapse (cystocele). However, it may cause entrocele (10-12%0, de novo detrusor overactivity by 10-15% of cases and 8-10% of cases may suffer of urinary retention. On the other hand the less invasive procedures like transvaginal tape (TVT), Trans obturator tape (TOT) and Spark. Most of these procedures may give more than 85% of continent rate. Local or regional anaethesia may be used for the procedures. Also, it may cause urinary retention or urethral or bladder trauma. Patients\' information leaflet should be given to her and briefly discussing the variable options.
Posted by A S.
Dr Paul
My answer was skipped ,would you please check it ,thanks
Posted by A S.
sorry not my turn yet
Posted by Ashwinibilagi25 B.
A healthy 40 year old mother of two has been referred to the gynaecology clinic because of urinary leakage on coughing and straining. (a) What additional information would you obtain from the history? [10 marks]
parity and mode of del time duration after last delivery/is she pregnant now?
duration of problem/fluid intake/caffiene intake
frequency
nocturia
incomplete emptying, urgency
frequency of incontinace and efect on quality of life
mass per vagina/dragging sensation
sexually active?
other medical problems especially connective tissue disorders

(b) What information would you obtain from the clinical examination [2 marks]

P/A to r/0 mass per abdo

P/s in left lateral position to perform POP Q score to r/o prolapse,
bladder neck mobility on straining
to assess the strength of pelvic floor

(c) Which initial investigations would you recommend given that clinical examination is normal? [2 marks]

MSU
dailty fuid intake diary
bladder diary
Urodynamics

(d) Her symptoms do not improve with conservative treatment and she is found to have urodynamic stress incontinence.
Evaluate the subsequent treatment options [6 marks].

taking her age in to consideration,
options would be
supportive management
can wait and watch for some more time if it is not affecting the quality of life which is rare in a 40 year old with future clinic apt to kno the progress
surgical methods
Burch colpo suspension

pros

80 -90 % success in first year
70 % patient satisfaction rate
permanent solution
no dysparaunia

cons

needs laparotomy
about 10.3 voiding problems post surgery
prolonged poeration time

tot/tvt

pros

no laparotomy
can be performed as a day case
1 st year success rate comparable to colposuspension
sooner recovery

con

dysparaunia
tape erosion
/infection
injury to bladder & ureters
vioding difficulties comparable to colposuspension

laparoscopic colposuspension

prso

aviods laparotomy

cons
longers operating time
needs expertise

ileo sacral suspension(laparoscopic)

long op tme
no long time studies available







Posted by Seema  B.
Dear Dr Paul
You have skipped correcting my answer.Can you please correct it.Awaiting to see the correction
thanks seema
Posted by Ahmad A.
Sorry Paul,
I think my answer was skipped, is it true? thanks.
Posted by Maayka ..
a) She should be asked about other urinary symptoms to elicit if there is a mixed picture of overactive bladder and stress incontinence – questions about frequency, nocturia, urgency and urge incontinence should be asked. Also I wish to find out if she has voiding dysfunction – strangury, postmicturtion dribbling, poor stream or sensation of incomplete emptying. Important also is the history of coitarchal incontinence and of stool and flatus and asking about possible vaginal wall prolapse symptoms. She should be asked specifically about the effect of her symptoms on quality of life – need for pads, certain types of clothing and if there is diet restrictions imposed by her. Is there a use of anxiolytics and diuretics by the patient? Her diet should be looked into especially w.r.t. use of caffeine and total fluid intake. If she is a smoker and alcohol user, this would influence her management. Her past obstetric history is relevant if she had a prolonged second stage and episiotomy, especially greater than third degree laceration repaired. Her future reproductive ambitions and sexual function would be useful in planning her treatment. It is important to inquire about earlier surgical attempts to treat her symptoms, as it will influence subsequent chosen options.

b) Her measurement of BMI and abdominal/ pelvic examination will be done. The latter to determine if there are any abdominal masses and to elicit stress incontinence with a cough reflex. A check of pelvic organ prolapse e.g. for a cystocele will be useful in deciding subsequent treatment.

c) An MSU for ruling out urinary tract infections and a urinalysis to check for protein/ nitrites immediately. An outpatient bladder ultrasound to check residual volume (postvoiding). A bladder diary for 3 to 5 days can be done.

d) Treatment options for this patient are either medical or surgical now. Duloxetine, an SNRI, can be used while she is awaiting surgical options or if she chose this while planning / deciding if future pregnancy desirous. It helps by increasing the urethral sphincter mechanism control.
Surgical options will be influenced by the presence of pelvic organ prolapse. If there is none then Burch Colposuspension can be done under general anaethestic either abdominally or lapascopically and it has a success rate (continence) of 85 – 90% at 1 yr and 70% at 5 yrs. Slings such as the transvaginal tape (TVT)
Can be done under local aneasthetic in same day surgery and it has a success rate of 85- 80% at 5yrs. It is a shorter procedure than Burchcolposuspension with lower postop morbidity. Anterior colporrhapy can be done if a cystocele is also present but success rates not as great as the above 2 procedures. Transobturator tape is another option but increase risk of bladder injury vs. TVT. Also, techniques like needle suspension techniques which involve injecting a synthetic material on either side of the proximal urethra has lower success rates at 1 yr vs. the previous techniques