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MRCOG PART 2 SBAs and EMQs

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Essay 235 - Incontinence

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		Posted by Mohammad H. Fri Jul 6, 2007 02:08 am
a-I will tell the patient that this leakage may be due to de nove detruser instability(D I) that ocuurs in up to 18 % of cases following colposuspension. failed lapaoscopic colposupention in first five years following operation is about 25-30 % . Urinary tract infection also may be the cause of this leakage.the presence of DI in accompany to GSI (MIXED incontinence) may be the cause o this leakage as colposuspension will treat GSI only. b-History about the current symptoms ,if there is is urgency,freouency,nocturia or leakage on cough or strain and how much these symptoms affecting her life..The presence of dysuriaand hematuria coincide with urinary tract infection (UTI). History of precipitating factors as cough ,constipation. Life style factors as excessive alchol intake , tea ,cofee . History of previous treatment or operations before colposuspension . Examination ;body mass index(BMI),chest examination, abdominal examination for abdominal mass.Local examination to detect leakage on cough. Midstream urine sample for bacteriologic examination and culture and sensetivity,random blood sugar,chest x-ray and abdominal ultrasound. Urodynamic studies to differentiate GSI from DI. c-Options for treatment include non medical , medical and surgical methods Non medical treatment include change in life style (stop smoking,reduce alchol intake,taking caffeine free drinks ) may be effective in mild DI as these subtances are irritant to the bladder. Treatment of precipitating factors as obesity ,chronic cough ,chronic constipation. Bladder retraining is effective in ~30%of caseswith DI . Medical treatment of DI is mainly depending on anticholinergic agents as oxybutinin,toletoridine and trospium which are effective but are limited by their side effects as dry mouth and blurred vision which are dose related with o9xybutinin associated with more side effects than toletoridine and trospium. Desmopressin is also effective being associated with less urine production. darafinacin and solofinacin are associated with less side effects and they are effective in cases of DI . Intermittent self catheterization in intractable cases . Surgical treatment; Re-operation in cases of failed colposuspension for GSI as tension free vaginal tape (this should follow urodynamic studies and inclusion of urosurgeon). In case of DI surgical interference in the form of ileal conduit is of limited value and limited only to cases where other measures fail. Incident form should be filled .
		Posted by Dr. Umme H. Sat Jul 7, 2007 12:22 am
a. I will tell her about the possible cause of her symptom which includes urinary tract infection which is quiet common, detrusor instability which may occur as a complication of burch colposuspension, leakage of urine may occur due to overflow distention as a result of voiding dysfunction, failure of the operation leading to persistence of her previous symptom of GSI. Urinary tract injury can also occur as a complication of the procedure. b. To diagnose the case careful history should be taken regarding the symptom whether it present before the operation or present as a new one. Any history of cough or constipation should be asked for. Presence of symptoms of UTI should be asked; adequate voiding was demonstrated or not at the postoperative period should be reviewed. Operative findings should be reviewed from operation note to detect whether there was any difficulty arise during operation and review of post-operative record should be done to detect any voiding difficulty arise in the post-operative period. Review of pre-operative urodynamic investigations is to be done, which may give an idea about the presence of detrusor instability and voiding dysfunction before the operation. Chest examination is to be done to detect any respiratory tract infection. Her BMI is also to be assessed. Examination is to be done to detect any pelvic mass or full bladder. Pelvic examination is to be done to detect any obvious leakage, presence of any scarring, sign of urogenital atropy is to be noted. A midstream specimen of urine should be examined for C/S. Ultrasonography is to be done to detect any pelvic mass or full bladder. If history, clinical examination and simple investigation exclude other cause then urodynamic investigation is to be done to detect genuine stress incontinence or DI. Urinary tract injury followed by urinary fistula can be diagnosed by 3 swab test and cystoscopy if needed. c. Proper counseling is to be done prior to the initiation of any treatment and psychological support should be given. The treatment option of the patient will be according to the underlying causes. If there is any aggravating factor like cough or constipation it should be treated. She should avoid smoking or caffeine, modify her fluid intake, location of the toilet should be changed and different clothing may improve her symptom in detrusor instability. Bladder retraining is helpful in motivated pt. Anticolinergic drug like Oxybutynin and Tolteredin are effective. These drugs have some unwanted adverse effect. Tolteredin have better side effect profile. Side effect includes dry mouth, blurred vision, constipation, abdominal discomfort .A course of antibiotic should be given in case of UTI according to C/S report. In case of overflow distention due to voiding difficulty, some patient will require life-changing intervention like self-intermittent catheterization. If GSI is confirmed then further surgical intervention may be needed. This surgery should be done by an urologist who is expert with the procedure. Before doing this, appropriate counselling is to be done regarding possibility of low success rate associated with repeat surgery. Some form of sling operation would be the procedure of choice if the recurrent urethral hyper mobility is noted. If the urethra is well supported, we would then consider injection with a urethral bulking agent. In case of urinary tract injury, continuous catheterization is to be done for six to eight weeks which may lead to spontaneous healing. If fails then appropriate surgery is to be done by an expert urological surgeon.
		Posted by Saad A. Sat Jul 7, 2007 09:29 pm
a.I will counsel her in a sympathetic & sensitive way as this is an awkward and difficult situation for the patient to accept the same clinical presentation for which she had been treated six weeks back preferably I will counsel her along with her partner and midwife. I will tell her that the leakage could be of failed surgical procedure, or it could be due to failed detection of exact symptoms of detrusor instability +GSI that there could be mixed incontinence before surgery, then I will explain the symptoms can also be affect of complication of operation like fistula formation and also there is a chance of detrusor instability even after surgery of GSI (as a complication). I will also tell her about urinary tract infection which is a part of complication of surgery. b.The first thing to reach the diagnosis is ask about the detailed history, she should be asked the present symptom, whether she has got the problem of urge incontinence, urgency, leaking on coughing, sneezing , increased frequency of urine, nocturnal enuresis she will be enquired for chronic cough and constipation .Then her examination will be done , her abdomen will be examined to see for any mass, vaginal examination to see urinary incontinence, Boney?s test will be done to document stress incontinence ,then her pelvic examination is done to feel the site of fistula if present ,mid stream urine to exclude urinary tract infection, ,her blood sugar test will be required to exclude diabetes mellitus ( DI ), there will be a need of urodynamic assessment in case mixed pattern to exclude detrusor instability and GSI. She will be given the frequency urine chart to have a record of fluid intake and output (3 days). Dye test will be needed if there is clue of fistula, to know the exact site within ureter or bladder, and then need of intravenous urography to locate exact site of bladder fistula. Cystoscopy will be needed in case of bladder fistula. Ultrasound is needed to see for residual urinary volume & if any other pathology. c.The options available for treating her symptoms are first the patient should be told about the conservative measures like improvement of health, chronic cough and constipation is treated. The patient is advised for restricted fluid diet, avoidance of tea, coffee, alcohol which increased urinary frequency. The treatment will depend on the cause detected, in case of urgency, urge incontinence (DI), the patient will be advised antimuscaranic drugs. Most common oxybutine but side effects of any drug will be told to the patient. Sarfenacin is next drug with less side effects can also be given.Tolteridone has got efficacy but side effects of blurring of vision & dry mouth .The patient will be offered Oxybutin patch or intravesical oxybutin. Education of bladder drill will be given. If there is persistent stress incontinence symptom, then the surgery will be repeated but only in the presence of urologist & the patienbt will be advised for complete assessment by urologist. The options are TvT in which sling is pass transvaginally, TOT, same as TVT but more chance of bladder perforation. The other procedure used in case of failed surgery is para urethral injection & urinary diversion(only in specialist clinic).If fistula is suspected repair is advised according to urologist, time and technique is decided by urologist and bladder has to be catherised for 6-12weeks depending on the surgery. The bladder fistula can be repaired abdominally and vaginally. The urinary tract infection will be treated with antibiotics according to culture report. Incident form will be filled.
		Posted by Fahima A. Sun Jul 8, 2007 01:50 am
a) The causes may be due to the complications of surgery like retention of urine followed by overflow incontinence as in 10-12% cases of colsuspension there is voiding difficulty. Detrusor instability may be another cause of leaking either arises denovo( 18%) or was present previously. The colposuspension is successful in 80-90% cases in 1st year & 70% in 5th year, so failure of the procedure may a cause of her leaking. She may have the urinary tract infection (UTI). Though rare but there is a risk of fistula formation (either vesico-vaginal or ureteric ). Rarely any new pathology can also be the cause of her incontinence. b) History should be taken from the patient whether she leaks on coughing , sneezing & whether she has developed chronic cough, constipation after surgery to exclude stress incontinence. Leaking with urgency goes in favor of Detrusor instability & dysuria in favor of UTI. She should be enquired if she could void spontaneously after removal of catheter. Her case note also should be reviewed to see whether her residual volume of urine was measured by ultrasound scan to exclude voiding difficulty. Continuous leakage may be the cause of urinary fistula. Abdominal examination will reveal full bladder in voiding difficulty. Vaginal examination may reveal fistula or stress incontinence. A urine dipstick will give a clue of UTI. An ultrasound scan will diagnose voiding difficulty or any other pelvic mass. If there is suspicion of stress/ urge incontinence bladder diary should be maintained & urodynamics is to be done or repeated if done previously. 3 swab test, dye test, cystoscopy, intravenous urogram should be reserved for diagnosis of fistula. c) Treatment should be according to the cause. Psychological support is important as she may be upset. If voiding difficulty is detected reassurance should be given that it will be cured over time. By this time intermittent self catheterization or continuous catheterization is advocated. In urge incontinence fluid modification, bladder training and oral oxybutynin is first choice of treatment. The side effects of oxybutynin are dry mouth, blurring of vision, constipation. If patient can not tolerate these effects tolterodine, solifenacine, trospium or oxybutynin patch can be given. If failed surgery patient can be given option for repeat surgery. Before that chronic cough and constipation should be corrected if present. Transvaginal tape (TVT) is the better option in previously failed surgery than colposuspension. It has 80% success rate in 1 & 5 year. Side effects are voiding difficulty (4%), bladder perforation. Periurethral injection with bulking agent can also be considered. It is simple, can be repeated but success rate is low. If UTI is detected is to be treated with antibiotics. If vesicovaginal fistula is diagnosed continuous catheterization or if big surgery is the option. After surgery continuous 2-3 weeks catheterization is done. Ureteric fistula if present surgery should be done in collaboration with urologist. Incidental form should be filled up.
		Posted by Natalie P C. Sun Jul 8, 2007 07:39 am
A The likely cause is exacerbation of or de novo detrusor overactivity (DO). After a colposuspension, there is a risk of detrusor overactivity as a side effect. It may be de novo or it may be an exacerbation or previously mild symptoms. The second option would be failure of her surgery with recerrence of her genuine stress incontinence. Another possible cause is a fistula (vesico-vaginal). B I would take a thorough history. What makes her leak and when does it occur. Does she wear a pad because of this. DO is suggested by symptoms of urgency, urge incontinence, frequency and nocturia. Stress incontinence is suggested by leakage triggered by activity like coughing of sneezing. Fistula is suggested by a constant leakage. I would investigate which activities make her leak to assess the severiy and how it is affecting her quality of life. Examination should rule out a cystocele and show no demonstable stress incontinence. I would then do some investigatons. A urine specimen for culture and sensitivity to rule out a urine infection. I would also request urodynamic studies. This will show if there is any detrussor overactivity. C First line is conservative treatment with a reduction of consumption of caffeinated drinks and not drinking very late at night to reduce nocturia. These are associated with a small amount of improvement for women. The mainstay of treatment is anti-muscarinic (anti-cholinergic) drugs. These produce a good reduction of urgency episodes and reduction of pad wearing. Side effects include dry mouth, blurred vision, constipation and dizziness and these can be quite severe for these women. Intolerability is a major drawback. Other options include estrogen therapy but there is no evidence of benefit. Antidepressants with tricyclics have shown some benefit.
		Posted by Valerie T. Sun Jul 8, 2007 07:42 am
A healthy 57 year old woman attends the gynaecology clinic 6 weeks after laparoscopic colposuspension for genuine stress incontinence. She complains of urinary leakage. (a) What will you tell her about the likely causes of her current symptoms? [4 marks]. (b) Logically outline your diagnostic approach [6 marks]. (c) Evaluate the options available to treat her symptoms [10 marks]. a) I will tell this lady that the likely causes are: 1. Urge incontinence. The colposuspension was performed to treat stress incontinence. It does not treat urge incontinence. 2. Stress incontinence. Although the colposuspension was done to cure the stress incontinence, the operation has an associated failure rate. It may take some time before stress incontinece is cured or the condition may improve but it may never be 100% cured. 3. Bladder injury. There is a small risk of injury to the bladder during colposuspension. 4. Urinary tract infection. b) I would take a detailed history to determine the onset and duration of the urinary leakage. I would find out whether there is continuous leaking of urine or only at specific times. I would find out whether there is a history of urgency, leakage of urine during laughter or coughing, frequency, nocturia or dysuria. I would also enquire as to whether this lady feels that her bladder is emptied fully after urination and whether the stream of urine is continuous or in spurts. I would perform a physical examination. I would do an abdominal examination to determine if there was any distension, tenderness or palpable masses in the abdomen. I would do a speculum examination to determine whether there was uterine prolapse, cystocele or rectocele. I would also ask her to cough, to see if there was any leakage with coughing. I would do a vaginal examination to palapate any adnexal masses, the size of the uterus and shape of the uterine fundus. I would request investigations. Urea, creatinine and electrolyte blood tests to determine whether her kidney function was normal. A urine test to identify a urine infection. An ultrasound scan to identify any pelvic pathology. Urodynamic studies to determine whether the leakage was due to stress incontinence, urge incontinence or a combination of them. Cystoscopy to identify a bladder injury. c) If the diagnosis is stress incontinence, I would suggest pelvic floor exercises, reducing or stopping the intake of caffeine and losing weight. I would discuss the option of having a tension free tape inserted to treat stress incontinence. I would also provide written information in the form of an information leaflet and also give a follow up appointment. If the diagnosis was urge incontinence, I would offer her medical treatment. I would explain that there are different tablets available and that they were associated with different side effects. I would provide written information and a follow up appointment. If the diagnosis was bladder injury. I would suggest surgical repair of the injury. I would offer referral to the urologist. I would discuss the risks of not repairing the injury, for example continuous leaking and a vesicovaginal fistula. I would explain the procedure and length of time that she would stay in hospital and postoperative care. If the diagnosis was a urinary tract infection, I would explain the diagnosis and offer antibiotic treatment. Following the treatment of the condition, I would arrange a follow appointment.
		Posted by AMNA K. Sun Jul 8, 2007 05:08 pm
a) I will tell her that although it is difficult to give her (without investigations) the exact cause of her symptoms but it could be because of detrusor instability(DI) which was not picked up previously or it is a complication of colposuspension which occurs in every 17 patients out of 100, in which bladder contracts involuntarily and leads to the loss of urine . Other causes could be urinary tract infection(UTI) or injury to the urinary tract at the time of surgery which is also inevitable in some cases.There is possibility that surgery itself was not successful in correcting her original problem. b)In order to diagnose her problem detailed history and examination supported by appropriate investigations is required. History include exact duration and nature of symptoms, continous leakage or dribbling( leakage immediately afer surgery and continuously indicates injury to urinary tract).Other symptoms like , urgency, urge incontinence nocturia(detrusor instability),dysuria , frequency, haematuria(urinary tract infection) must be asked. Severity and impact of symptoms on her social and personal life,complains related to faecal and flatus incontinence should also be enquired and exacerbating factors like excessive fluid intake,cafeine or cola drinks and alcohol must be explored. Regarding examination general physical examination will be unrewarding as she is healthy. Abdomen will be palpated for abdominopelvic masses and fullbladder(chronic retention),pelvic examination for atrophic vaginitis , pelvic masses and mobility of vaginal wall ,speculum examination to look for leakage of urine although fistula may not be demonstrated clinically .Investigations required include mid stream specimen urine (MSU) plus dipstix test for protein, blood, leucocyte,nitrates and glucose and culture sensitivity to rule out and treat infections before proceeding for urodynamics .Pelvic uss if abdominopelvic masses suspected and for bladder volume if voiding difficulties, Urodynamics if infections is excluded to differentiate between GSI and DI so treatment can be targted accordingly. Examination under anesthesia cystourethroscopy and dye test if fistula is suspected. c)Regarding options of treatment, it has to be according to the cause and includes general measures like modification of fluid intake and caffeine ,avoidance of smoking and reduction of alcohol. UTI will be managed with a course of antibiotics and voiding problems by teaching intermittent self cathetarization. If urodynamics favours DI then bladder retraining and /or anticholinergics will be recommended as first line therapy Anticholinergics includes tolterodine, solifenacin and oxybutynin all are almost equally effective(50 to70%succes rate) and has side effects (dry mouth, constipation, blurred vision) and but tolterodine has better side effects profile so patient,s compliance is better.Tricyclic antidepressents are given for nocturia and nocturnal enuresis but causes drowsiness and postural hypotension . Estrogens can be given to relieve symptoms of urogenital atrophy but cannot treat DI. If GSI is the diagnosis then patient can be given the options of conservative management( if not willing for undergoing surgery again) and includes pelvic floor exercises and drug therapy. Success rate of pelvic floor exercises is 27 to67 % if taught and targeted correctly preferably by physiotherapist for 15 to20 weeks and this should be offered even to those who are contemplating for surgery. Drug therapy for GSI is duloxetine which is a combine serotonin and noradrenaline re uptake inhibitor it increases urethral sphincter activity but has side effect of nausea , dry mouth , headache and dizziness. If she is willing for surgery then surgery should be planned in collaboration with urologist and after appropriat counseling regarding success rate as secondaryprocedure . Suitable options for surgery in this case are tension free vaginal tape(TVT) or trans obturator tape(TOT) which are least invasive and with good efficacy as secondary procedure(85 to 95%) with short term voiding problems but no long term voiding problems and there is risk of bladder perforation(TVT) and groin pain(TOT).Other options if surgery fails, are para urethral bulking agents if urethra is not well supported to increase the bulk of urethra and urinary diversions if problem is intractable and should only be performed in specialist clinic . If fistula is diagnosed the bladder is catheterized for 6 to 12 weeks to give chance of spontaneous closure and if closure does not occur then repair should be planned.
		Posted by Malar R. Sun Jul 8, 2007 09:21 pm
The causes are a urinary tract infection, constipation, failed treatment with colposuspension, de novo detrusor instability, development of a prolapse or a fistula secondary to the operation. Her symptoms need to be reassessed , whether they are the same as before or are new. Is the urinary leakage associated with nocturia, frequency, pain, haematuria, urge or constant needing to wear incontinence pads. Also the timing of the onset of symptoms is important to check if they continued from the operation or have developed following an interval. Ideally she should attend the clinic with a fluid input output chart(bladder diary) over a period of 3 days to assess her symptoms.Her bowel habits should be enquired about to exclude constipation. She should be examined vaginally to demonstrate the type of incontinence, if there is persistent stress incontinence or continuous leakage possibly suggestive of a fistula.Examination should include checking for vaginal wall proplase and careful inspection for the presence of a fistula.Constipation should also be excluded as this can lead to overflow urine incontinence.Her abdomen should be examined to check for adequate healing of her scars and exclude any new masses or tenderness which could suggest an infection. A mid stream urine should be sent for culture and sensitivity.She should be sent for urodynamic studies to assess the type of incontinence especially if there are signs of mixed urge and stress incontinence.If there is a suspicion of a new mass present, an USS of her abdomen and pelvis must be carried out to characterise the mass. If a fistula is suspected , an pelvic MRI with contrast can be carried out to diagnose the site of the fistula or an examination under anaesthetic with a cystoscopy. The treatment options depend on the cause of the incontinence. It a urinary tract infection is confirmed , then treatment with an antibiotic to which it is sensitive might cure the problem.Constipation should be treated with enemas and laxatives.She should be followed up after this to ensure resolution of problems. If it is de novo detrusor instability, then she should be advised fluid restriction, with bladder retraining with the input of an incontinence advisor with the possible use of anticholinergics. If stress incontinence has recurred, this is a treatment failure and the options are physiotherapy or repeat operation. Physiotherapy can work in up to 50% of women but requires motivation and intensive sessions. If a repeat procedure is to be considered, the patient should be referred to a urogynaecolgist and transvaginal tapes or Open colposuspension can be considered but the success rates are limited. Alternatively the patient might not want any further treatment and can use incontinence pads if acceptable to her and restrict her total fluid input.
		Posted by Idris O. Mon Jul 9, 2007 04:06 pm
a) I would inform her she may have de novo detrusor instability or unsuccessful repair for stress urinary incontinence. The other possibility is urinary injury with the development of uterovaginal fistula or vesico vaginal fistula. b) History The duration of incontinence because most urinary injuries usually but not invariably presents within 7-10days of surgery. The presence of dysuria, urgency and frequency suggest UTI. If have urgency, frequency with urge incontinence and nocturia this suggest detrusor instability while urinary incontinence on coughing , laughing or walking may suggest stress incontinence. Intermittent period of incontinence suggest uretero-vaginal fistula while total incontinence suggest vesico vaginal fistula. Examination for pelvic floor muscle strength and unsuspected vaginal prolapse. Investigation would include mcs of urine for UTI, frequency volume chart to determine frequency and severity and a post void residual urine to determine voiding dysfunction and the likelihood of success at repeat operation. Urodynamic investigation is indicated where conservative measures have failed and before any subdequent surgery. Intravenous urogram and cysto urethroscopy would be required if injury to the bladder or ureter. C) Treat UTI if present. Patient should be advised on sensible fluid intake and avoid coffee in the evenings. Pelvic floor exercises successful in about 75% if supervised and good motivation. Biofeedback could be obtained with perineometer and or weighted vaginal cones. This may be complemented with duloxetine which increases the success rate but associated with nausea. Detrusor instability is treated with bladder retraining with success rate of 50-75% and can be combined with anticholinergics but poor compliance because of side effects of dry mouth, drowsiness and constipation. No good evidence of efficacy of HRT and or topical oestrogen. Surgery in the form of repeat colposuspension is associated with success rate of 65-70% at 5yrs and corrects cystocele but is an abdominal procedure with failure of about 10-20%. Similar success rate with retropubic procedure of TVT , is performed vaginally and sometimes under sedation and associated with less side effects. Bulking agents with collagen, teflon or silicone useful when diagnosis of intrinsic sphincter deficiency is made or other procedure has failed but associated with short long term improvement and need for repeat procedure. The use of artificial sphincter has a last result is associated with a high morbidity and need for further surgery. Treatment of surgical vesico vaginal fistula is associated with success rate of 80-90% and ureteric injury is managed with implantation with success rate of 75%.
		Posted by Parveen Q. Tue Jul 10, 2007 09:06 am
The common complication after colposuspension is voiding difficulty which occurs in about 10%of cases, this can lead to retention with overflow. The other cause could be detrusor instability which occurs in about 17%after colposususpension, but it can occur even prior to surgery . Urinary tract infection is another cause. Any fistulas like vesicovaginal fistula, ureterovaginal fistula can occur. The diagnostic approach depends on the severity of symptoms and how it affects the quality of life. History of preoperative urinary symptoms like frequency, nocturia, urge incontinence can be taken. The nearness of toilet, figidity of clothes will be noted. Abdominal examination for suprapubic swelling(enlarged bladder)done. Cough test to see if there is any stress incontinence.Pelvic examination to identify dermatitis which is secondary to ammoniacal crystals of urine. Investigations like MSU for culture and sensitivity, vaginal fluid for biochemistry if in doubt. Dye test performed in litotomy postion with both full and partial bladder as some oblique tract fistulas are missed in full bladder. 3swab test done. In vesicovaginal fistula, clear urine seen in vagina. Other tests like IVU and cystography are less sensitive. Retrograde pyelogram is useful in ureterovaginal fistula. cystoscopy may show chronic inflammatory changes. fistulogram, or vaginogram are other options. Treatment options depends on the cause of symptoms , woman\'s wishes, compliance of the patient and available expertise. For in continence-Treatment of constipation, chest infection offers benefit in 50%of patients. Urinary infection treated by appropriate antibiotics. Pelvic floor exercises if done under supervision by physiotherapist , effective cure is expected but takes long term 15-20weeks. It is suitable for those reluctant for reoperations. Mechancial devises like bladder support prosthesis, improves quality of life, success rate upto87%, but complications like cystitis, excess vaginal discharge can occur. Medical treatment like oestrogen replacement has subjective improvement but has short term effects like nausea, GI symptoms and long term effect like increase incidence of DVT and breast cancer risk. Duloxetine, (serotonin and noradrenalin reuptake inhibitor) improves qualtiy of life, reduces incontinence rate, but not recommended as 1st or 2nd line therapy but useful in those who donot wish to have surgery. it\'s side effects are dryness of mouth and has withdrawl reactions like dizziness, anxietty, parasthesia upon abrupt withdarawl, so needs to be withdrawn over a 2week period. surgical treatment is sling procedures like TVT,which is suitable for previous colposuspension patients, but failure rate is high if TVT done in such patients, It\'s success rate is 85-90%in 5years. Other complications are sling erosion, bladder perforation. Transoperator foramen procedure uses similar tapes like TVT but long term efficacy data not available. Periurethral collagen/macroplastique injections has low morbidity but needs repeated injections. other rare options are artificial sphincter, neourethra . Incase of fistula, longterm catheterisation in anticipation of spontaneous closure. It may take 6-8weeks, needs patient\'s co operation, sufficient continence pads should be provided.Perineal care from ammonical crystals of urine prevented by silicone barrier cream. prophylactic antibiotics given.surgical repair can done abdominally or vaginally.Postoperative care is vital in form of adequate fluid intake , check catheter output hourly. Maintain free drainage for 2-6weeks , and integrity checked by dye test before removal of catheter. thromboprophylaxis should be provided. incident forms prepared.