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MRCOG PART 2 SBAs and EMQs

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Essay 269 - Urogynaecology

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		Posted by hoping .. Wed Jul 16, 2008 06:21 am
A healthy 57 year old woman complains of nocturia, urinary frequency, urgency and urge incontinence but no other symptoms. (a) Justify your clinical assessment and investigations [8 marks]. (b) What will you tell her about the cause of her symptoms, given that clinical assessment is normal? [2 marks] (c) Evaluate the non-surgical treatment options [10 marks]. Her symptoms are suggestive of overactive bladder syndrome.This could be associated with high levels of anxiety and distress thus effect of these on her quality of life should be gathered. Her fluid intake habits should be explored as some modification may reduce severity of her symptoms. If she experiences any vaginitis symptoms or prolapse should be specificaly enquired as treatment may need to me modified. If she had any previous operation for incontinence should also be enquired.Patient should be examined abdominally to rule out any abdominal or pelvic mass that may be pressing on bladder. It may also reveal full bladder with no sensation indicating neuropathis blader.Vaginal examination to rule out prolapse and atrophic vaginitis. Anterior vaginal wall mobility and visible stress incontinence should be checked . Uterine siza and presence of adnexal masses should be checked.Her Body mass index should also be calculated as reducing weight in obese women improves symptoms. Investigations should include urine dipstick and culture if infection is suspected. Pad test can be employed to detect incontinence though it is unreliable in determining type of incontinence. Pelvic ultrasound should be arranged if abnormal mass is suspected. Scan also indeifies bladder calculus or thickened bladder wall sugestive of detrusor overactivity. Fluid intake and output chart over minimum three days should be reviwed to detect severity and pattern of problem .Cystometery helps determine type of incontinence or low compliance bladder and urolowmetery to rule out voiding dysfunction. Ambulatory urodynamics should be considered when symptoms strongly suggestive of detrusor overactivity with failed other investigations. Post Void residual bladder scan helps to identify overflow incontinence or voindg dysfunction.Electromyography is used if neuromuscular disorder suspected. She should be informed that this is common problem affecting women more often than men. It is due to hypersensitivity of bladder without any obvious identifiable cause. Treatment options involve maintaining body weight within healthy range for her height. She should be advised to drink 1-2 litres of water as this reduces risk of cystitis and avoid caffeine because it is irritant to bladder. avoiding fluids 2-3 hours before she goes to bed may help nocturia. She should be advised to stop smoking if she smokes. Pelvic floor excercises are more effective for stress incontinence but should be tried for any incontinence as first measure if patient agrees. Bladder retraining involves slowly increasing interval between micturition to upto 3 hour. This is effective and noninvasive intervention but involves patient motovation and can take few weeks to show benefit. Anticholinergics like oxybutynin, tolterodine are effective in symptom control but symptoms return upon discontinuation. They are also associated with significant side effects like drymouth, constipation and thus upto 50% patients discontinue treatment.Intra vesical botox injection is effective and tried in patients when other meaures fail. Its effect wears of with time and some patients may need intermittent self catheterisation. Supportive measures and incontinence advisor are valuable in improving quality of life. Patient should be advised about incontinnece pads for protection when incontinence occurs.
		Posted by Priti T. Wed Jul 16, 2008 07:13 am
a]The cause of her symptoms could be Detrusor Overactivity/Instability[DI],in which the bladder contracts involuntarily leading to the loss of urine.Other causes could be UTI or Bladder Retention with overflow.Detailed history includes exact duration and nature of the symptoms:- nocturia,urgency,frequency,urge incontinence[DI],haematuria[UTI].Severity and the impact of these symptoms on her social and personal life [Quality of Life] should be asked.Exacerbating factors like excessive fluid intake,caffeine/cola drinks and alcohol must be explored.She can be asked to maintain a urinary diary for further details. Regarding the examination, abdominal examination is done for detecting the abdominopelvic masses and full bladder[chronic retention].Pelvic and local examination is done to detact atrophic vaginitis,pelvic masses and ammonical dermatitis due to the urine leak.Speculum examination is done to rule out leakage of urine[GSI] or the fistula which may not be demostrated clinically. Routine Investigations include 1]MSU plus dipstik for the proteins,blood,leucocytes,nitrates,glucose and the culture sensitivity to rule out and treat infections before proceeding to urodynamics.2]The simple non invasive Pad test[the women performs a variety of activities while wearing a pad for one hour] is limited to providing more objective quantification of incontinence.3]A Frequency Volume Chart allow for a more objective analysis of the symptoms.A suspicion of detrusor overactivity can be raised by the presence of marked frequency,varying voided volume of nocturia.These investigations are followed by the special investigations. Cystometry forms the basis of the diagnostic test for the Detrusor Overactivity;but it is costly,time consuming,invasive and has a significant number of false negative for detrusor overactivity.Simple cystometry has been criticised as being non physiological.Ambulatory Urodynamic Monitoring[AUM] has been advocated.This has a high pick up rate for the phasic instability,but is prone to artifact,difficult to interpret and requires complex ,expensive instrument. Videourodynamics, where the cystometry is supplemented by the radiological contrast studies provide the anatomocal information and is considered as the GOLD standerd of the urodynamics investigation.TVS [trans vaginal sonography] is a reliable screening test for the detrusoe overactivity[measrement of bladder base more than 5mm] as well as residual urine detaction. Cystoscopy would br indicated if the patient has small bladder capacity,poor compliant bladder or haematuria. b] Patient should be reassured in view of the normal clinical assessment, that Detrusor Overactivity is a very common cause of her symptoms and accounts for 30-50% of those investigated.Further she should be told that some conservative measures and drugs can treat her without resorting to any surgical options. c]Various non surgical options of the treatment can be divided into conservative and pharmacological. Conservative measures include advice regarding the fluid intake.Women should be advised to consume fluids 1-1.5 Lit/24 hours.Caffeine/alcohol should be avoided.UTI can be managed by the course of antibiotics.Voiding problems can be managed by teaching the patient intermittent self cathetarisation. Bladder retraining is advised for the detrusor overactivity and has a cure rate of 44-90%.The principle of bladder training is based on the ability to suppress the urinary urge and extend the interval between voiding till a suitable time span of 3-4 hours.Pelvic floor exercises are also advised with bladder retraining to suppress urinary urgency.Barrier creams can be prescribed for the ammonical dermatitis. Pharmacological interventions include numerous preparations having high placebo effect of 30-40%.Response of any other anticholinergics used are in the range of 60%.Tolterodine is the first line of anticholinergic drug used for detrusor overactivity.It is well tolerated with similar efficacy to oxybutynin ,but fewer adverse effects like dry mouth.Trospium chloride is another anticholinergic effective in inhibiting detrusor contraction ,and has fewer adverse effects than oxybutynin.Darafenacin and solifenacin are in the final phase of clinical trials and may be available in future. Oxybutynin,long recognised as an effective form of treatment for detrusor overactivity.It has antimuscranic side effects[dry mouth,constipation,blurred vision],which can be minimised by changing the route of administration.Intravesical oxybutynin has been shown to increase bladder capacity;rectal administration has fewer adverse effects.Recently OROS-controlled release oxybutynin preparation has been developed using osmotic system. Antidepressent Imipramine 75mg at bedtime can be useful for the treatment of nocturia.Its rarely used as first line of drug due to serious side effects like orthostatic hypotention and ventricular arrythamias. Oestrogens have been frequently prescribed to treat the symptoms of urgency and urge incontinence even though there is little objective evidence to support their use.
		Posted by Sam M. Wed Jul 16, 2008 08:43 am
clinical assessment would be based on history and examination,as evident from question in history she has no other symptoms except nocturia ,frequency , urgency and urge incontinence,I would like to know how adversely these symptoms affect her quality of life,and her weight will be important in further management . on abdominal examination distended bladder because of urinary retension . on pelvic examination as she is menopausal signs of atrophy ,vaginal dryness, thinning and may be vaginitis, ,uterine or ovarian enlargement which are asyptomatic on bimannual pelvic examination ,bladder neck support. assessment. Pad test is not now recommended .she will be given information and advice about maintenance of urinary diary for atleast 3 days including working and leisure time ,To rule out asymptomatic urinary tract infection ,a urine dipstick will be performed and if no leucocytes or nitrites ,no further action will be taken but (if they are present then a urine microscopy and culture will be performed and antibiotics will be prescribed according to sensitivities.).on the basis of clinical assessment it will be categorized as overactive bladder syndrome or stress incontinence or mixed .to diagnose overactive bladder investigations like multichannel filling and voiding cystometry are not performed as primary investigations as they are performed before surgery if have detrusor overactivity or previouse surgery is failed. Part b, ,I will explain her that clinical assessment suggest an overactive bladder which means her bladder response to stimuli like caffeine ,excessive fluids has increased ,this conditions respond well to conservative treatments as bladder training and pharmacological ,and she doesnot need to have a urodynamic assessment before starting a conservative treatment. Part c.if she has bmi >30kg/m2 then weight reduction will be advised ,her first line treatment will be bladder training for atleast 6 weeks ,she has to increase her interval between voidings gradually from one hour ,reduce intake of caffeine espeiaaly before bed times ,avoid uncessary fluids before bed time ,and fluid intake to 1.5 litre according to weather.despite of this routine if frequency and nocturia persist ,desmopression for troublesome nocturia and second line therapy are anti muscarinic agenst as non propriatry oxybutynin and she will be told about the side effects as dryness of mouth ,dry eyes ,constipation, if that not tolerated then review her again and change to tolterodine,/darifenacin,and early reviw after change of drung is recommended. She is postmenuasal so better to have a locally acting estrogen for vaginal atrophy,if pharmacological treatments failed and patient will be explained about the other nonsurgical treatments like uterosacral nerve stimulation after preliminary assessment on peripheral nerve,I will tell her that a longterm follow up is required so information leaflet will be provided .botulinum toxin a for detrusor overactivity can be given to her after informed consent and explanation especially self catheterization, complemantory therapies have no role in management of detrusor overactivity.
		Posted by R M. Wed Jul 16, 2008 07:08 pm
a) Her symptoms are suggestive of overactive bladder/urge syndrome. furthue investigations will be done based on this diagnosis from patient history and symptoms. I’ll try to identify the severity of symptoms and effect on quality of life; I’ll also try to identify the most distressing symptoms and exacerbating factors such as diuretics, excessive fluids, and caffeine intake and lifestyle factors such as location of toilet and fiddly clothing. I’ll also enquire about any past neurological illnesses or similar episodes in the past. I’ll assess her Body Mass Index; an abdominal and pelvic examination will be done to exclude any palpable bladder, abdomino-pelvic mass or any utero-vaginal descent. I’ll have a quick neurological examination to exclude any primary neurological disease. I’ll do MSU and dipstix for blood, protein, leukocytes and glucose to exclude UTI and diabetes mellitus. I’ll ask the patient to maintain a bladder diary/frequency-volume chart to assess the severity of the condition and functional bladder capacity. Urodynamic investigations are not indicated in this case as she is not having any mixed symptoms unless there is history of failed treatment. Ultrasound assessment for pelvic mass if clinically indicated, it will also help to assess bladder volume. Cystoscopy to exclude causes of sensory urgency like bladder tumors or interstitial cystitis and biopsy of the lesion if any. b) In the absence of any other pathology I’ll tell her that the problem is detrusor over activity and urge syndrome-a condition where there is occurrence of uncontrolled spontaneous contraction of the muscle of the bladder called detrusor. I’ll reassure her that there is no serious pathology which may satisfy many patients. I’ll also tell her that co explain her regarding the effectiveness of bladder draining. I’ll also tell her that there are other medical and surgical options available for her depending on the severity of her symptoms and the relief or failure with the initial therapies .I’ll provide her with written information. c) Nonsurgical treatment options include lifestyle modifications, bladder drill and medical therapy using anticholinergic drugs, tricyclic antidepressants, antidiuretic hormone and estrogens. There is significant placebo effect with most treatment with ~50% success rate and high relapse rate Lifestyle changes like change in location of toilet, change in type of clothing, modification of fluid intake and reduction of caffeine intake may improve quality of life. Weight reduction will be advised if BMI is high. Bladder training and biofeedback will be the most effective first line treatment option offered to patients with overactive bladder and urge syndrome. Up to 90% women become continent compared to 23% in control group; 40% relapse rate at 3 years. No side effects compared to drug therapy. Better outcome with inpatient treatment but has cost implications. If bladder training is ineffective or if frequency remains troublesome consider treatment with anticholinergic drugs. Nonproprietary Oxybutynin will be the initial choice as it is more cost effective. But significant side effects including dry mouth, constipation, visual disturbance and voiding difficulties may limit compliance. Improvement in ~50 – 70% cases seen. If Oxybutynin is not well tolerated, newer agents like Solifencin or Darifenacin may be prescribed which has organ selectivity for bladder and hence less side effects and better tolerance; but long-term data on use not available. Tolterodine and Propiverine also have less side effects. Tricyclic antidepressants have anticholinergic effects and are also sedative – useful in nocturia. Side effects include drowsiness and postural hypotension. ADH / Nasal desmopressin also useful in nocturia; contraindicated in cardiac disease and in women on diuretics. Side effects include fluid retention causing hyponatremia; epistaxis, nasal congestion and rhinitis with nasal spray. Estrogen is effective in relieving symptoms of urogenital atrophy in postmenopausal women but no evidence of proven efficacy in detrusor instability. Inravescical therapy using Botulinum toxin or Capscaisin is very useful in those willing and able to self catheterize; lack of long-term data; special arrangements for research and audit should be in place. In women with urge syndrome who also have cognitive impairment, prompted and timed toileting programmes may help reduce leakage episodes. Routine use of electrical stimulation in OAB is not recommended.
		Posted by Asma kamal K. Wed Jul 16, 2008 08:20 pm
(a)In clinical assessment of this woman a detail history and examination is very important. I will ask her about the duration and the rate of progression of her symptoms. Impact of these symptoms on her quality of life and personal hygiene. I will enquire about her L.M.P and associated atrophic changes in the urogenital region, which may be evident with the symptoms like dysparunia, atrophic vaginitus(itching). To exclude different causes of her symptoms I will specifically ask her about any bladder pain, dysuria, hematuria to rule out interstitial cystitis. I will ask about nocturnal enuresis and incontinence during coitus(for over active bladder). I will ask about continence for faeces and flatus to rule out any neuorelogical cause and pelvic floor injury. I will also ask about her parity and mode of deliveries. I will ask her about any precipitating factor like type (caffeinated) amount and timing of fluid in take,type of cloths she wear and the location of toilet. I will also enquire about her concerns ,desire for treatment and expectations from the treatment. After taking history with the consent of the woman I will examine her. On per abdominal examination i will look for any mass or distended bladder. I will do perineal examination to rule out any ammoniacal dermatitis. On per vaginal examination I will look for the signs of atrophic vaginits, uterovaginal prolapse, urethral caruncle. On bimanual examination I will try to rule out any mass. To rule out neurological cause I will do neurological examination. I will send MSU for culture and cytology to rule out urinary tract infection,dipstix to check for heamaturia, nitrates ,glucose and protein. Frequency volume chart to assess the severity of the problem, capacity of the bladder and her fluid in take habit. Pelvic ultrasound to rule out pelvic mass if clinical assessment inconclusive ,Cystoscopy with or without biopsy if heamaturia on dipstix or bladder pain to rule out bladder tumor and interstitial cystitis. Urodynamic investigation not required initially but if the empirical therapy fails then I will ask for urodynamic investigations. (b) I will explain to the women that in view of her clinical assessment she is having an over active bladder, which means that her bladder contract spontaneously and involuntarily and leads to her symptoms. Mostly the cause is unknown and in view of her normal findings the cause behind her over active bladder is also unknown. I will reassure her that there is no sinister pathology. (c)Simple explanation and reassurance about the cause of her symptoms may help. General advise regarding change in life style measure will also help, like change in the location of toilet, change of cloths, and change in the time of fluid in take i.e less fluid in take in the evening and no fluid intake in the night. Decrease in the in take of caffeinated drinks and alcohol because they irritate the bladder. Bladder drill and biofeed back has good effect , they may show relapses. In patient biofeedback very effective but costly. Medical therapy can be give which has high placebo effect (30-40%). Response to any drug is around 60% with very little difference among them. Oxybutynin has mix effect, anti muscarinic, direct muscle relaxant and local anesthetic effect. Efficacy and safety of oxybutynin is well documented but the frequency of its side effect limit is clinical usefulness. side effect include dry mouth, dry skin ,dry eyes, constipation diarrhea abdominal pain, blurred vision, voiding difficulties, dizziness’, restlessness and arrhythmia. These side effects can be minimized with decreasing the dose, route of administration (rectal, intravesical) and formulation (slow release formulation).Other alternatives are tolterodine and trospium with same efficacy and minimum side effects. Newer agents like darafenacin and solifenacin with equal efficacy and very less side effects due to receptor selectivity. Long term data on there safety still awaited. Tricyclic anti depressant can also be used but they cause sedation and serious side effects which are rare but serious like orthostatic hypotension and ventricular arrhythmias. Desmopressin can be used which decreases the production of urine.The side effects are hyponatremia and rihinitis and nasal congestion. Both tricyclic anti depressants and desmopressin are not the first line treatment and are more effective on nocturia rather than frequency,urgency and urge incontinence . Local or systemic estrogen for urogenital atrophy may be effective but usually does not effect over active bladder. Hypno therapy and homeopathy may help.
		Posted by Manoj M. Thu Jul 17, 2008 04:01 am
a. Urinary incontinence has significant physcial and psychosocial impact on the affected patients and also on NHS resources, so it is important to categorise from her presenting symptom this as overactive bladder syndrome(OAB) and to differentiate from other causes like stress and mixed urinary incontinence because treatment is directed to the presenting symptoms. Any history suggestive of urinary infection with dysuria or if dipstick shows nitrites and/leucocytes needs further testing with midstream urine sample for culture and sensitivity and treat urinary infection based on testing results or if symptomatic before results because this may be the cause of urinary incontinence. A bladder diary would be able to help is assessing her fluid intake, quantity of intake and related association of her incontinence which is use full in conselling her for symptom relief. A bladder scan may be useful in preferance to catheterisation to measure post void residual which may suggest voiding dysfunction or urinary infection. It is important to identify other associated causes that may need referral like associated with haematuria or recurrent urinary tract infection may need urology review, finding a palpable bladder after voiding may need neurology evaluation and if consistent with symptomatic uterovaginal prolapse at or below introitus may need surgical repair as an option. Other investigations like urodynamics may be required if initial treatment is not helping or to differentiate underlying stress incontinence which may be beneficial prior to surgial treatments. b. If her clinical assessment is normal she should be said about her diagnosis of OAB which is a common condition with her bladder being irritable and causing her a combinations of her symptoms, this is not a life threatening condition but maybe affecting her quality of life significantly. There are many treatment options to help her have a better quality of life but sometimes it is a challenge to give complete symptom relief. c. Counselling on reducing caffeine related fluids intake as these can be bladder stimulants and reduction may improve symptoms like urgency and frequency which may be the only advice required especially in women taking large quantities of caffeine intake. Bladder training advice like bladder drills exercises which helps symptom relief preferrably with the help of physiotherapist for a period of 6 weeks is recommended as this will help symptom relief is a majority of women with OAB and also avoid anticholinergics which are associated with many side effects but if still symptomatic it is advisable to consider anticholinergics like oxybutynin which may be associated with side effects like dry mouth, constipation which could be reduced with extended release preparation/ patches or with other antichonergics like solifenacin/ tolterodine. Intravaginal estrogen may be beneficial with vaginal atrophy presenting with OAB and desmopressin may help to reduce OAB with signifiacnt nocturia but suggest caution with use as may cause fluid retention and hyponatraemia especially used in caution with hypertension or cardiac diseases and also as not licenced to use for this purpose needs informed consent for treatment. In women with cognitive impairment, prompted and timed toileting may be helpful to reduce leaking episodes.
		Posted by Farina A. Thu Jul 17, 2008 05:23 am
a)Clinical assessment will include further inquiry about burning micturation or past history of UTI. Strong family history of diabetes melblitus may suggest diabetes. The degree of impairement of her social life is also important to know. Examination is usually unremarkable. Investigations will include a MSU for analysis and culture sensitivity, in order to rule out UTI. Glycosurea and fasting blood sugar can diagnose diabetes malitus. Cystometry is helpful as it shows failure to inhibit the detrusor contractions during the filling phase. b)I would like to tell her about the diagnosis and the pathophysiology and reassure her that it is a benign disease which can be significantly improved with various nonpharmacological and pharmacological methods resulting in improvement in quality of life. Written information should be provided. c)Non surgical treatment options includes bladder drill, in which patient is advised to pass urine on predetermined time intervals and the intervals are gradually increased. Life style modification is one of the essential advises, which includes fluid restriction and avoidance of tea, coffee, alcohol and beverages. Adequate dressing which are easy to remove and avoidance of too much clothing is valuable to avoid embarrassment in case of incontinence. Pharmacotherapy is the commonest and effective method to improve symptoms. The commonest drug is oxybutanin which is muscarinic receptor blocker (M1 and M3) it is 53-85% effective, but long term use is limited by the side effect profile (constipation, dry mouth and blurring of vision). Extended release preparation has a better side effect profile. Tolteradine is also a M1 and M3 receptor blocker. With a batter side effect profile than oxybutanin and a comparable effectivity. Trospium chloride is an atropine derivative. Effectivity is comparable to oxybutanin with a lower side effect profile. It is lipophyllic so crosses the blood brain barrier and produces CNS side effect so not suitable for the elderly. Propiverine is an anticholinergic and calcium channel blocker. Effectivity is comparable to oxybutanin and a batter side effect profile. Darifenacin and solefenacin are highly selective muscarinic receptor blocker with minimum effects on the salivary glands. Efficacy is comparable to oxybutanin. Drugs suitable for the elderly are tolteradine and darifenacin because they cannot cross the blood brain barrier so has minimum side effects.
		Posted by H H. Thu Jul 17, 2008 05:34 am
Clinical assessment starts with taking history including severity of the condition and effect on quality of life.Her lifestyle and drinks including alcohol, tea and coffee consumed are noted.Any medications taken.I would ask of fecal incontinence associated.Also if there are menopausal symptoms as dry vagina ,dyspareunia or hot flushes. Examination is done to exclude abdominal masses.I would look for ammonical vulval dermatitis on local examination. Also exclude associated vulval prolapse, assess mobility of urethera and if bladder is full ask her to cough to demonstrate if stress incontinence present. A mid stream specimen of urine is taken for culture and sensitivity.Urine dip stikes can be used to exclude glycosuria or proteinuria .Advise the patient to keep a urinary diary to assess bladder capacity and frequency of micturition.Residual urine can be estimated by urinary catheter after the patient passes urine or by pelvic ultrasound. Further investigations like urodynamic studies are not done at this stage. The patient is told that if clinical assessment is normal and in absence of glycosuria or urinary tract infection, most probably her condition is due to over activity of her bladder muscle(Detrusor over activity), and that there are measures to treat it. This condition can be treated with application of changes in her lifestyle ,including limitation of amount of drinks and beverages like alcohol,tea or coffee , diet and exercise and distracting her mind .I should know the value of placebo therapeutic effect of different methods on her condition. Let her have faith in my treatment and supply her with written information. If no improvement ,bladder drill is done the idea of which is training the bladder to accommodate more urine. In patient bladder drill is mor effective but more costy. Patients with nocturia and frequency due to menopause can find improvements with vaginal estrogen cream. Medical treatment in the form of ant cholinergic drugs such as oxybutinin can be used but has side effects like dry mouth and constipation.It should not be used in patients with glaucoma or those liable to urinary retention.Tolterodine is better tolerated and has less side effects.Solfinacin acts locally on bladder with few side effects.Serotonin release inhibitors have been shown to be effective.Desmopressin which has antiduiretic action will limit urine output. Other methods including neuromodulation eg posterior cutaneous nerve stimulation has shown to be effective. On managing such patients it should in a multidisciplinary care ,following local guidelines and protocols involving proper counseling and taking informed consent before applying treatment.Improving treatment can be done by proper auditing of different treatment modalities.
		Posted by J P. Thu Jul 17, 2008 08:12 pm
a. These symptoms may suggest the possibility of detrusor instability (overactive bladder syndrome). I will enquire about the quality of life affected by the symptoms like limitation of social mobility. I will also have a detailed history regarding duration and severity of symptoms. I would like to know the symptoms which bother her much like nocturia or incontinence. A careful enquiry of symptoms with suggests urinary tract infection like suprapubic pain will be done. I will ask about her caffeine, alcohol intake which may influence the symptoms. Any history of chronic constipation leading to uterovaginal prolapse will also be asked. I will do an abdominal examination to look for any abdominal mass and bimanual pelvic examination to rule out uterovaginal prolapse.Investigation would include midstream urine for nitrites, leucocytes, pus cells to rule out urinary tract infection. A frequency volume chart will be monitored for both diagnosis and management. I will do pelvic ultrasound if the pelvic examination is inadequate or a possibility of mass. b.I will tell her that since the clinical assessment is normal, there is possibility that the reason for these symptoms is due to over activity of the muscle detrusor which makes bladder continent which is known as overactive bladder syndrome. I will tell her that this is due to rise in detrusor pressure during filling phase of cystometry which should not be there in normal condition. I will also reassure her that these may be relieved by life style changes in my overactive bladder syndrome. c.Life style changes are very important in the management of overactive bladder syndrome. Restriction of fluid intake or changes in timing and frequency intake is important. This can be achieved by maintaining frequency volume chart. Reduction in caffeine and alcohol intake should be advised. Change in position of toilets and use of continence pads may also be useful. Bladder drill and biofeed back by continence nurse specialists will ensure 90% continence rate but the disadvantage is the 40% relapse in 3 years. The high continence rate is achieved in inpatient care but the cost effectiveness factor precludes it’s use. Transcutaneous and electromagnetic stimulation of sacral nerve plexus can also be tried but its effectiveness is controversial. Pharmacological management includes the use of anticholinergics like tolterodine, propeverine, oxybutinin. The success rate is 57 – 70%. But the disadvantage is the side effects like dry mouth, blurred vision, constipation, urinary retention which is less common with new drugs like trospium, solifenacin. Tricyclic antidepressants may also be used but the risk of drowsiness and postural hypotension should be kept in mind. Desmopressin can be of use in symptoms like nocturia and urge incontinence. Estrogen replacement in postmenopausal women may be helpful in controlling nocturia, urgency and urge incontinence but the clinical evidence is limited.
		Posted by Drxyz A. Fri Jul 18, 2008 04:00 am
a) First of all I shall take detailed history of the patient. Duration and severity of the symptoms, for how long she is menopause. Any history of urinary tract infection, Uetero vaginal prolapse, COPD, Vaginal surgery, abdominal mass. History of intake of coffee, alcohol and water intake. Past medical history regarding diabetes, HTN and any drug intake. I shall ask her about the impact of these symptoms on her social and sexual life. on examination I shall assess her general condition, systemic examination for COPD, abdominal examination for any mass and local examination. In local examination I shall inspect the vulva vagina and do speculum examination to see the anterior and posterior vaginal prolapse and uterine prolapse. if possible I shall manifest the stress incontinence by asking her to cough with full bladder to see the incontinence. I shall request for MSU to exclude the UTI. Provide patient with urinary diary for frequency and volume charting. Pad test to assess the incontinence by weighing the pad. After excluding the UTI, USG bladder for thickness of detrouser muscle. Referral to urologist for urodynamic studies like cystometry to see the relationship between pressure and volume of urine. Uro-flowmetery to see the flow rate of the urine. video cystouretherography to visualize the urethra and bladder for any abnormality. Electromyography to see the integrity of the nerve supply to detrouser muscle. b) Considering the symptoms and normal clinical assessment most probable diagnosis is detruser instability. I shall explain to the patient that in this condition the bladder muscle becomes irritable and even with low volume of urine the muscle activates and leads frequency, nocturia and urge incontinence. I shall tell the patient that this is not a serious disease and can be treated without surgery. c) Among non surgical methods first is Psychotherapy e.g bladder drill but it takes more time to take effect, there is high relapse rate and need highly motivated person to be effective. Behavioural therapy like to decrease the fluid intake before going to bed. Accupuncture, Tense, hypnotherapy can be recommended. Medical treatment including the drugs which decrease the detruser contractility like anticholinergic drugs like oxybutanine. Most effective drug but has side effects like dry mouth. it can be given intra vesicle but for this we have to insert catheter. Toltaridine can also be given. Tricyclic anti deprassnats like imperiamine. Alpha adrenergic stimulator to increase the outlet resistance. In postmenopausal patient estrogen therapy may improve the symptoms because of raised sensory thresh hold of the bladder. Desmoprssin can used to decrease the urine output.
		Posted by g.b. D. Fri Jul 18, 2008 12:57 pm
The above symptoms can be due to due to detrussor instability,uncontrolled or undiagnosed diabetes mallietus, or side effects of various drugs like diuretics.a well directed history will aid diagnosis.A past history of any medical illness like hypertension and medications for it, recurrent uti,surgeries like hysterectomy or for stress incontinence should be enquired. it is likely that these symptoms have occured postoperatively. social history should include the severity of symptoms, their effect on daily activities, amount of alcohol and coffee intake. a family history of diabetes may point to undiagnosed diabetes. A thorough general and systemic examination including bp, CVS and RS should be carried out to asses any comorbidities. A abdominopelvic examination should be done to r/o pelvic masses like fibroid uterus and urogenital atrophy or a cystocele. examination should be followed by investigations like urine routine and culture to r/o bacteriuria, and blood tests,GTT, to r/o diabetes . a baseline rft and electrolytes can be done to r/o any renal dysfunction. Patient must be asked to maintain a frequency volume chart - urinary diary- for 2-7 days. this is simple noninvasive invaluable tool and includes active participation of patient in management. It will give idea of qunatity timings and freq of viods and intake. It will also give clue to natural volumetric capacity of bladder. this chart can be used baseline and repeated after treatment to check effectiveness of treatment.A ultrasound examination of pelvis should be done if there is any clinical suspicion of pelvis mass and to measure residual urine.An emperical treatment with anticholinergics and bladder retraining can be given for 6- 8 weeks before investigating further.A urodynamic study can be done after UTI is ruled out to avoid ascending infection. if there is no response then urodynamic study can be done. this will diagnose the exact etiology like low compliance bladder, detrussor instability,orinstrinsic sphinctor deficiency. these tests include filling and voiding cystometry and urofolwmetry. the results should be interpretated by expert and he may ask for further tests like videourodynamics if required. since there is no dysuria or hematuria there is no need for cy stoscopy. b) we will reassure her that the clinical examination is normal.Sometimes the bladder may become oversensitive and its capacity of compliance may be reduced. so it gets stimulated even with small quantities of urine.it is not a life threatening condition however may affect daily life. it can be caused by various conditions and may need to maintain a urinary diary for asses the severity. the treatment may take a long time and sometimes may not be possible to get cured completely. c) the nonpharmacologocal methods include lifestyle modification like reducing coffee and alcohol intake. modification of fluif intake like restrictins fluid intake after 7 pm may help to control nocturia. bladder retraining is an effective therapy. the patient s asked to void at regular intervala and the intervals increased over a period of time. initiall she may be asked to viod every 1 hrly then when this control id well achieved then 1 and half hourly, and then after 2weeks 2 hrly. a urinary diary is maintained during this period to chart any wetting episodes. electromyographic stimulation of bladder musculature can be done with tens , electrodes applied over applied over t10 to l1 and s2-4 or with electro magnetic therapy. acupuncture is a emerging alternativeand need treatment from specialist in that area. pharmacological methods are mainstay of treatment for detrussor instability. the commonly tried options are oxybutinin, propavarin and tolterodin. oxybutinin is anti muscarinic and has a local anesthetic action also. howevre the compliance to treatment is affected due to various bothersome anticholinergic adverse effects . they are dryness of mouth,taccycardia, blurring of vision, and constipation. adverse effects can be reduced by giving rectal preparations which are equally effective has become a first line drug now.it is tarted gradually with 1mg and then 2 mg acn be continued bd for 8-10 weeks. tolterodin is equally effective with less adverse effects and hence compliance is better. newer drug solfinacin is long acting antimuscarinic agent available for detrussor instability. ostrogens can be prescribed locally if there is clinical evedence of urogenital atrophy. anti depressants like imipramin have been tried for nocturia hoever serios side effects like hypotension and arrythmias preclude its use. all the medications may take 8 weeks to be effective and treatment should be given for 3-4 months. running short of time... took 27 mins to make plan and write it... pl let us know which part can be omited .
		Posted by SHAGUFTA T. Fri Jul 18, 2008 07:34 pm
A) I will take detailed history of her symptoms regarding duration of symptoms and its severity, whether primary or started after any previous surgery. I will enquire about impact of symptoms on her quality of life. I will ask her about previous recurrent Urinary tract infections, hematuria. I will take her Past medical & surgical history, if she is suffering from chronic cough or constipation. Any H/O congestive cardiac disease. Is she taking any drug like diuretics (which may mimic these symptoms). H/o any pelvic Irradiation or surgery. Her past obstetric history regarding tears or fistulae, prolonged 2nd stage, short interdelivery interval, grand multiparity (more prone to develop genital prolapse). I will ask her to keep volume input- output chart, urinary diary to assess later. On examination—I will do her general examination including weight, BMI calculation, Blood pressure, Chest & heart auscultation (to look for Chronic bronchitis / signs suggestive of CHF). I will proceed with abdominal examination to exclude any abdominopelvic mass causing pressure symptoms. Then I will do vaginal examination to look for uterus, cervix, adnexae, any prolapse, any fistula. I will perform cough test to look for stress incontinence. Investigations—I will order urine dipstick for blood, protein, sugar, leukocytes. If suggestive of UTI, proceed with urine Culture, Blood sugar to exclude diabetes mellitus. If hematuria, cystoscopy to be done. USG abdomen + pelvis will be done to exclude any mass, renal pathology. Urodynamic study not indicated unless treatment failure is there. B) I will tell her that if there is no mass, UTI or hematuria most likely diagnosis is Detrussor instability. I will explain her that this is not a serious condition. In this condition, muscles of bladder becomes overactive and contract either spontaneously or in response to stimuli. I will tell her that she may get better with only lifestyle changes, or with drugs, rarely needs surgery. C) After doing all investigations and evaluation of severity of her symptoms, I will discuss with her conservative and pharmacological options of treatment keeping her wishes in consideration. Proper explanation of her condition and reassurance will be enough in some women. Advice on lifestyle modification like reduction of weight if obese, if smoker to stop smoking, avoid excess tea, coffee, alcohol will help some patients. Maintainence of fluid intake to 1-2 litres per day, less fluid before going to bed with help in preventing nocturia. Advice on proper clothing and placement on toilet facility will also help. Behavioural theray is also effective where Pt is taught to control stimuli. Bladder drill and Biofeedback is effective mode of treatment but needs expertise and costly, and also needs strong motivation. Written information leaflets to be provide If conservative measures fail, next option is pharmacological management. Most frequently used first line agents are anticholinergics like Oxybutynin, tolterodine. They have good efficacy and significant symptom reduction but have S/E like dry mouth, blurry vision, voiding difficulties which may lead to stop medication early. Trospium & propiverine have less S/E. Newer agents like solifenacin is also effective but still under trial and no long term data available. Diuretics and desmopressin also tried, may help in treatment of nocturia, safe in long run, licenced in UK, but contraindicated in cardiac insufficiency. HRT with estrogen replacement might help if other menopausal symptoms like urogenital atrophy coexist. Pt should be informed that all treatment modalities have almost 50% success rate and long term relapse so regular followup is needed.
		Posted by H P. Sat Jul 19, 2008 06:46 am
(a)Clinical assessment should aim to identify relevant predisposing and precipitating factors. I will take a detailed history regarding duration and progress of her symptoms, the most predominant symptom and its impact on her work life and personal hygiene. I would enquire about her fluid intake including caffeinated drinks and alcoholic beverages and the timings of her intake. I would ask about duration since her last menstrual period, her parity and mode of delivery. I would ask about her way of clothing and location of toilet. I will like to know about her concerns for her treatment and her expectations. I would check her BMI. I will do a per abdomen examination to rule out palpable bladder or a mass. I would examine the external genitalia for presence of ammonical dermatitis due to chronic exposure to urine and post menopausal atrophy. I would do per speculum examination to look for vaginal discharge, atrophy, uterovaginal prolapse or urethral caruncle. Bimanual examination for pelvic mass and mobility of anterior vaginal wall is done. Digital assessment of pelvic floor muscle contraction should be undertaken. If there is suspicion of neurological deficit, she should undergo thorough neurological examination. Investigations would include mid-stream urine (MSU) sample for dipstix to check for hematuria, nitrites, glucose, protein and leucocytes. If proteins and/ or leucocytes are positive, I will send MSU sample for cytology, culture and sensitivity. If it is positive for glucose, she should be investigated to rule out diabetes mellitus and in case of hematuria she should be referred to specialist. I would encourage her to maintain a frequency –volume chart for atleast 3 days over her working and leisure hours. A bladder ultrasound for post- void residual urine volume is arranged. In case of suspicion of fistula on per speculum examination, a dye test is done. Urodynamic studies may be required if initial pharmacological therapy fails. (b)I would explain that it is most likely due to overactive bladder and in most cases, exact cause is not known. It occurs due to spontaneous uncontrolled contractions of bladder muscle during the period when it should normally be relaxed. Behavioral therapy and medications are helpful in most cases. However, treatment may be prolonged and may not give her complete relief. I would provide her with written information. (c)Treatment should take into account her needs and preferences. In case, her urine culture report is showing infection, proper antibiotic treatment is given along with 1.5-2 liters of oral fluids daily. If all her initial investigations are normal, she would be managed as detrusor instability and urge incontinence. While evaluating any therapy, incontinence- specific quality of life scales like I-QOL should be used. General measures as to change of type of clothing and location of toilet are necessary. Life style modifications include a trial of caffeine reduction and alcohol consumption. She should be asked to modify her high/ low fluid intake. She should drink about 1.5-2 liters of fluid daily, while avoiding too much fluid after 7pm. If her BMI is more than 30, she should loose weight. Behavioral therapies include bladder retraining which is the first line treatment for a minimum of 6 weeks. If there is no significant benefit or if frequency is the main complaint, an antimuscarinic agent may be added. Medical treatment has a high placebo effect (30-40%). Response to any drug is about 60% with very little difference in relief but mainly in side effects. She should be counseled about the chances of relapse and need for long term follow up. Immediate release oxybutynin is given first. Oxybutynin has mix antimuscarinic, direct muscle relaxant and local anaesthetic effects. She should be explained about the side effects like dry mouth, dry eyes, dry skin, constipation, voiding difficulties and dizziness. Written information should be provided. If side-effects are intolerable, oxybutynin can be given in extended release form or by transdermal route. Tolterodine, trospium or darifenacin may be used as alternatives. An early treatment review should be undertaken following any change in antimuscarinic drug therapy. Propiverine is helpful to treat increased frequency. Desmopressin nasal spray is helpful to specifically reduce nocturia but as it is not approved in UK for idiopathic cases, informed written consent should be taken. Side-effects include rhinitis, nasal congestion and hyponatremia. Intravaginal oestrogen may help if she has vaginal atrophy. She should be informed about support groups like The Continence Foundation.
		Posted by Atashi S. Sat Jul 19, 2008 02:22 pm
(a)For clinical assesment patient should be asked for duration and severity of her symptomes,its effect on quality of life. Patient should be asses regarding her desire for treatment .History should be taken regarding excessive fluid and caffeine intake, location of the toilet and fiddly clothing wearing.On examination sigh of atrophic vulvo vaginitis is to be noted.Cough test is to be done to demonstrate any obvious leakage .presence of utero vaginal prolapse need to be detected . Abdomino pel vic examination is to be done todetect any abdominal or pelvic mass.Freequency and volume chart and urinary diary should be maintained.Mid stream specimen of urine is to be tested. Dipstick for blood , protein , leukocytes , nitrites and glucose. pelvic scan to exclude pelvic mass if clinical pelvic assesment is inadequate. Urodynamic assesment in case of mixed symtoms or failed emperical treatment.Cystoscopy if haematuria ,bladder pain or or reduced bladder capacity at cystometry. (b)As clinical examination is normal I will tell her in this situation cause is unknown. There is no underlying pathology .Some modification of life style will improve these symtomes in most of the cases.( c)Explanation of the diagnosis and reassurence is sufficient in some women .Life style modification is tobe advised such as location of toilet and change in type of clothing .Biofeedback and bladder drill up to 90% of women become continent compared to 23%in the control group. 40% relapse rate with in 3years.Better outcome with in patient treatment but has cost limitation. Anti cholinergic drugs -Oxybutynin, Tolterodine,Propiverine, solifenacine may improve57to71%of women .They have significant Placebo effect. Side effect espiallydrymouth appear to be less common with newer drugs like solifenacin. Oxybutynin has loal anesthetic effect. side effect includes nausea ,constipation, diarrhoea, abdominal discom fort,drowsiness, ,blurred vission ,voiding dif ficulty. Most common is dry mouth (88%).Tolteradine has similar efficacy but better tolerated . Propiverine is calcium channel blocker.Solifenacin is an newer agent with organ selectivity for the bladder over the salivary gland .Long term data are not avail able for this agent. Similar efficacy to other agent with respect to bladder function.Tricyclic anti depressant has anticholinergic and sedative effect. Usefull in nocturia and nocternal annuresis . Side effects are drowsiness and postural hypotention. Antidirutic hormone DDAVP-effective in nocturia and nocturnal anuresis provided women have no cardiac disease . and not taking any dirutics .Side effects includes fluid retention,hyponatremea , epistaxsis, nasal congestion and rhinities. .Oestrogen - effective in relieving symtoms of urogenital atrophy in post menupausal women(freequency , urgency and dysurea ).No evidence that it is effective in proven detrusor overactivity.
		Posted by Iffat ara M. Sun Jul 20, 2008 01:43 am
a):First of all I will gather information by history. The effect of symptoms on quality of life .How severe are the symptoms and duration of symptom..( any associate symptoms like symptoms of urinary tract infection ,haematuria, bladder pain). Fluid intake and caffeine intake would be inquired. Any drug therapy like diuretics, parasympathomimetic. Any previous continent surgery. I would ask about mobility/dexterity like location of toilet/type of clothing. Any medical history like cardiac failure, edema, hypothyroidism diabetes mellitus and chronic renal failure .then I will examine her thoroughly to exclude any abdominal or pelvic mass. By pelvic examination I will see the atrophic signs of Urogenital region. and will see for utero vaiganal prolapse Regarding investigation I will request urinalysis, MSU and dipsticks for blood, protein, leukocytes, nitrites and glucose . Frequency any volume chart (urine diary). Pelvic scan to exclude pelvic mass if inadequate clinical pelvic assessment. Urodimamic assessment, if failed empirical therapy. (Cystometry is not essential for diagnosis in female without stress incontinence). Cystoscopy if haematuria, bladder pain or reduced bladder capacity at cystometry. b):After detail history, examination and investigation I will explain the diagnosis with reassurance that there is no serious pathology. The lifestyle changes will improve the quality of life and relief of symptoms. c):Regarding non surgical treatment. i will explain her as there is no serious pathology. So simple life style changes such as location of toilet, change in type of clothing, modification of medical treatment such as diuretics and reduction of caffeine intake, fluid intake(about 1 to 1.5liters not in the evening) may improve quality life. Advise regarding bladder drill and biofeed (up to 90% of women become continent, 40% relapse rate occurs with in 3 years) better outcome with inpatient but has cost limitations. In medical treatment, antocholinergic drugs (oxybutynin, tolterodine, propiverine, solfinacin).Improvement in 57-71% of women seem with significant placebo effect associated with treatment. Side effects especially dry mouth appear to be less common with new agent like solifenacin. Tricyclic antidepressant useful the nocturia and nocturnal enuresis . Main side effects are drowsiness and postural hypotension .Anti diuretic hormone (DDAVP/desmopressin) effective in nocturia/nocturnal enuresis but contraindicated in cardiac disease and female on diuretics. Side effects include fluid retention with hyponatraemia, epistaxsis, nasal congestion and rhinitis with nasal spray.Estrogens effective in relieving symptoms of urogeuial atrophy (no evidence that it is effective in proven detrusor overactivity).
		Posted by SK K. Sun Jul 20, 2008 02:42 am
a)History taking is integral part of clinical assessment as it would point to severity of her symptoms & necessity & type of treatment required . Hence it is imperative that the patient be given enough time to describe her symptoms, concerns and expectations. I will enquire about the duration of symptoms, her occupation, how the symptoms affect her day to day routine, any restriction of her activities, intake of caffeine, alcohol, beverages, fluid consumption, smoking, duration since menopause, any HRT or previous medications taken for the condition.Also I would enquire of her last smear. . Clinical assessment would include calculating BMI as reducing weight would help in ameliorating the symptoms & also have other health benefits eg: cardio protection, a detailed systemic and local examination. Any evidence of peripheral neuropathy could point to neurogenic cause for the symptoms. Local signs of urethritis & vaginits would point to infective cause,any excoriation or dermatitis will point to severity of the incontinence . Also in view of her age, atrophic genital organs could also add to the symptoms. M. S.U for microscopy & culture as treatment of infection may itself cause resolution & there is need to treat infection before undertaking any urodynamic test.Fluid volume chart is very basic, simple & most important guide to knowing the women’s daily fluid consumption, total output , number of voids, episodes of incontinence, bed wetting.Pad test would give objective quantitative assessment. Uroflowmeter should precedes other investigation as decreased flow rate < 15 ml/ sec would point to voiding disorders. Cystometry would help in differentiating between SUI & DI Ambulatory UD study is more physiological and helps in giving accurate diagnosis. USG will demonstrate post residual volume & bladder wall thickness. B)given that the clinical assessment is normal the diagnosis of detrusor instability seems probable . I would explain to the lady that it is a chronic condition wherein the bladder muscle contracts spontaneously without being provoked or stimulated leading to symptoms of urgency, frequency , incontinence & even nocturia. It requires long term treatment , multidisciplinary care & most of all patients involvement, commitment & compliance. This condition requires more of behavioral modification for successful treatment along with medication. Role of surgery is very limited.if there is excoriation then she could use barrier creams . use of incontinence pads and napkins will help her in resuming her activities . C) the women should start by weight reduction as optimum BMI would help in ameliorating of symptoms. Fluid restriction to 1.5 L with severe restriction 2-3 hrs before going to bed will prevent nocturia & enuresis. Also cessation of caffeine, alcohol, beverages & smoking will add to the outcome. Mainstay of behavioral modification is bladder drill whereby patient is asked to voluntarily delay voiding for increased intervals by suppressing the desire to void. Physiotherapy , acupuncture, hypnosis would supplement behavioral modification. Anticholinergic eg: oxybutynin,flavoxates ., tolterodine, propantheline bromide help in improving detrusor instability but are limited by their Side effects like dry mouth, however if well tolerated can be used for over a 1 year with gradual tapering of dose. If this lady is already for some reason practicing sterile intermittent self catheterization, then intravesical oxybutynoin has showen to be effective. I would arrange for regular follow-up. So as to continue to motivate her & ensure her compliance .She will be provided with written information & put into contact with support groups.
		Posted by San S. Sun Jul 20, 2008 09:34 am
a)A fluids input and output diary would be useful which is normally sent out to patient prior to the outpatient appointment. A more detail history of the incontinence e.g. dysuria, terminal dribbling and sensation of incomplete emptying would give more information regarding the cause of the incontinence. It is also important to assess the severity of symptoms which may affect her quality of life. A history of her fluids and caffeine intake can help when giving her advice on the management of the problem. Her past obstetrics history, parity, mode of delivery and weight of babies can help to assess her risk of incontinence due to prolapse. Previous gyanecology history e.g. hysterectomy may increase her risk of detrusor overactivity and voiding dysfunction. Other relevant past medical history eg. neurological conditions e.g.multiple sclerosis affecting her bladder function or hypertension on diuretics may increase the frequency of micturition. She should be examine to rule out a pelvic mass that could cause incontinence abdominally and on bimanual examination. Atrophic appearance of vulva may suggest hypoestrogen state which sometimes can worsen urinary symptoms. A speculum examination should be carried out to look for any uterovaginal prolapse, urethral diverticulum which can cause urinary symptoms. It is also useful to get her to strain or cough to elicit signs of stress incontinence. First appropriate investigation would be urinalysis to rule out a urinary tract infection. An USS would be appropriate if a pelvic mass is suspected on examination. The next appropriate investigation would be a urodynamics study to find out the cause of the incontinence. b)The likely cause of her incontinence is detrusor overactivity in the absence of prolapse and stress incontinence. c)Advice on decreasing fluids intake at night time and also caffeine intake can help to decrease nocturia and frequency of micturition. If she is on diuretics, she could consider changing this to other antihypertensives, changing the dose or timing of administration after discussing with her physician. These are simple, non-invasive and non-pharmacological measures that works effectively. She could be offer bladder retraining with the specialist nurse. This is commonly use to increase the capacity of the bladder and extend intervals between micturition gradually. This method has shown to be effective and is non invasive and non-pharmacological method but may take several months to show significant improvements and would need encouragement and motivation to achieve good results. Pelvic floor exercise with the physiotherapist may be helpful in improving pelvic floor tone and help with symptoms. Again, this would need motivation and results may only be apparent in few months. Pharmacological methods with anticholinergice.g.oxybutynin, may help with symptoms a few weeks from commencement of treatment but there is side effects associated with e.g.dry mouth, blurred vision, constipation, etc. Especially in elderly people these side effects may not be well tolerated. Other newer drugs e.g. tolterodine and vesicare(muscarinic receptors antagonists) with better side effects profiles may be an alternative treatment options. Desmopressin may help if her symptoms is worse at night time. However, this should be used with caution in hypertensives, fluids retention patient. Topical oestrogen could be consider and may help with her symptoms if there is coexisting hypoestrogen state. She should be warn of risk of thromboembolism and breast cancer in long term use although the risks are far from systemic HRT.
		Posted by Shachi M. Sun Jul 20, 2008 09:12 pm
(a) Justify your clinical assessment and investigations. Clinical assessment will involve history taking, examination and investigations. The duration, onset and severity of symptoms should be assessed. It important to know if the patient’s symptoms affect her lifestyle or social life. The need to use pads everyday is an indicator of severity of symptoms. One should enquire about presence of any other medical problems (diabetes mellitus) which could cause frequency and nocturia. A history of current medication is important as diuretics can be the cause of frequency. A history of amount and type of fluid is important as caffeine and alcohol can aggravate urinary symptoms of frequency and nocturia. The presence of dysuria and presence of leucocytes, nitrates or protein in urine dipstck will suggest urinary tract infection. The presence of nocturia, urinary frequency, urgency and urge incontinence but no other symptoms and a normal urine dipstick is indicative of overactive bladder. The presence of haematuria should prompt investigations for renal stones or bladder malignancy, like ultrasound of KUB region or cystoscopy. An abdominal examination should be done to check for presence of any masses which could be giving rise to pressure symptoms. A vaginal examination should be done to check for urogenital prolapse, atrophic vaginaand any demonstrable stress incontinence. If urinalysis suggests infection a midstream urine sample should be sent for culture and sensitivity. The most important investigation in this patient is a 3 day bladder diary. A normal fluid intake with frequent voiding of small amounts of urine in absence of signs of infection is indicative of an overactive bladder. A urodynamic studies can be carried out if the symptoms do not respond to routine treatment measures. (b) What will you tell her about the cause of her symptoms, given that clinical assessment is normal? This patient should be informed that the likely diagnosis is overactive bladder, which means that the bladder muscles are very sensitive and contract at the slightest stimulus, giving rise to a strong urge to pass urine and sometimes cause leaking of urine. There are various non-medical, medical or surgical options available for treatment. Most women require lifelong treatment. This is not a serious or life threatening condition and she can chose not to receive treatment. c) Evaluate the non-surgical treatment options This patient should be managed by a trained urogynaecologist in conjunction with physiotherapist and continence nurses. The nonsurgical options available are, lifestyle advice (restrict fluid intake to 1.5 to 2 l per day, decrease caffeine intake, not to take fluids after 7-8 o’clock in the evening, stop smoking, exercise), bladder retraining and medical management. Bladder retraining usually should be with help of nurses specialised in urogynaecology. The patient is advised to pass urine at specific time intervals and the time interval between 2 voids is gradually increased. The success rates are good but but recurrence rates are high. Anticholinergics like detrusitol, torspium chloride, solefenacin, darifenacin can be prescribed. Derusitol has good efficacy but a poor side effect profile. All the other drugs have more or less similar efficacies and adverse effect profile. The side effects are mainly dry mouth, dry eyes and dizziness. Anticholinergics are contraindicated in women with closed angle glaucoma. Pelvic floor exercise and vaginal estrogens have limited role in management of urgency and urge incontinence.
		Posted by Shabana M. Sun Jul 20, 2008 11:53 pm
Most probable diagnosis in this case is overactive bladder(OAB) but a detailed assessment is required so that any associated problem could be manage effectively and efficiently Detailed history regarding severity and duration of symptoms and which symptom bother her most so that treatment can be tailored accordingly. Impact of incontinence on her social, and personal life(shopping,excercie sports and interpersonal relationship),copping mechanism(keeping pad, toilet mapping ,restricted fluid intake and frequent voiding).She will also be explored about her drinking habit as alcohol, coffee, tea and cola drinks are bladder irritants and can aggravate her problem, Previous treatment history and any pelvic surgery ,fecal and flatus incontinence as woman will not come out herself.Hitory of childhood enuresis will also be enquired due to its association with OAB. I will also enquire about hormone replacement therapy as menopausal symptoms can also aggravate the problem. General physical .examination will be unremarkable .Height and weight to determine body mass index and abdominopelvic assessment will be done to rule out any asymptomatic pelvic mass and full bladder for chronic retention which could lead to overflow incontinence. External genitilia will be examined for excoriation due to ammonical dermititis and degree of vaginal atrophy will also be examined .speculum examination will be done to rule out asymptomatic UVprolapse .Investigations include MSU for microscopy ,culture and sensitivity to rule out UTI as it is very common and treatable cause .If hematuria is found then cytoscopy will be advised to rule out malignancy .Frequency volume chart by asking to maintain urinary diary for 3 days will provide an objective evidence of her complains and will provide information about her drinking habitsacapacity of bladder and episode of incontinence along with time and will also serve as guide regarding treatment success. Pelvic ultrasound only if clinical findings are not conclusive and urodynamics will be needed if treatment failure or if surgery is contemplated as urodynamics are invasive and time consuming and expensive b)I will explain her that although most probable diagnosis in her case is hyperactivity of the bladder and in majority of cases(90%) no cause is found however it is not a life threatening condition and I will reassure her that there are effective ways to manage this problem c)Non surgical options include life style modifications like reduction of weight if obese , reduction of alcohol and caffeinated drinks and change in location of toilets and avoidance of fiddly clothing and adequate provision of continent pads. Theses are effective in 50% of cases,are natural , non invasive and not associated with side effects and and morbidity like surgery and are effective if symptoms are mild Bladder drill is bladder retraining or re education which is very effective especially if done as an in patatient if effordble,success rate is 90% although 40% relapse within 3 years but is non invasive and improves the self esteem and motivation of the patient. .Mainstay of treatment is pharmacotherapy and anticholinergic drugs are widely prescribed and include oxybutynin, tolterdine ,solifenacin and poaverine and derifencin .no one drug is superior to another ,all have side effects but have good efficacy and success rate is 60 to 70%.patients acceptability is better especially with different route of administrations (intra vesicle and intrademal)and extended release preparations which are associated with reduced side effects.Anesthetic and surgical risks are avoided and hospitalization is not needed,more in control of patient.Botulinium toxin type A andB (although not licensed in UK) given by injections endoscopically into the detrusor muscle at various points provide relief for 9 to 12 months, effective for those who are reluctant to use anticholinergic drugs or in whom pharmacotherapy has failed and they are not willing for surgery.vaginal estrogens have role in other symptoms of urogenital atrophy but has no role in overactive bladder
		Posted by Farkhanda A. Mon Jul 21, 2008 11:57 pm
I will make clinical assessment from history and investigations. Most probable diagnosis is overactive bladder or urgency syndrome, but I have to exclude other conditions such as urinary tract infection, mixed incontinen. In history I will ask about the duration and severity of symptoms and their impact on the quality of life .I will ask about any pain associated with micturation to rule out infection due to cystitis. I will enquire about any drugs like diuretics due to any heart or renal problem. In examination, I will check her body mass index ,which, if high then can give incontinence due to stress. I will do abdominal as well as pelvic examination to exclude any pelvo –abdominal mass . Investigations will include urin dip stix to see any blood, proteins, leucocytes and nitrates. I will give her a frequency / fluid chart to see her input and out put of fluids. Her mid stream urin will be sent to exclude any infection. Her symptoms are suggesting over active bladder ,but even then urodynamics can differentiate this or mixed incontinence. I will arrange cystoscopy to rule out any tumor, interstisial cystitis with additional benefit of taking biopsy if indicated. If suspicion of neurological cause, I will refer her to neurologist. I will arrange pelvic ultra sound scan to exclude any pelvic cause to irritate her bladder to give her these symptoms. B I will tell her probable cause that her bladder is overactive and confirmation will be done after all investigations. I will explain that her symptoms are due to overactive bladder and it is not life threatening condition . It can be treated by medicines ( which are the main and most effective option of treatment), as well as surgically and conservatively. I will also warn her to avoid some routine habits like coffee, smoking and fizzy drinks if I pick these things from her history. C Non surgical options of treatment include bladder drill or re-training. In this she will be taught to go to toilet at pre-determined time and slowly this time interval be increased. This is quite effective method. To make it more effective, patient should be in- patient and nursing staff also involve for moral support , But it is not cost effective. Life style modifications can have significant contributions in improving symptoms such as access to toilet , easy removing clothing , and not drinking coffee, tea and smoking. Bio-feed or electrical stimulation of bladder muscles is effective but long term outcome is unknown. Pharmacological treatments is non properitary oxybutilin which has effects on MI M3 receptors. It is effective but its use is limited due to side effects such as dry mouth, constipation and blurred vision. Tolteridine is also more or less like oxybutilin. Newer drugs such as darifenacin and solifenacin have more selective action on bladder muscles receptors and so less side effects. Trospium chloride is also quite useful. Tricyclic anti depressants such as imitriptalin and desmopressin can give sedation and help in nocturia by producing less urin. Placebo is effective but relapse rate is very high on cessation. Oestrogen is effective in atrophic urogenital but its effecy is not proven. All these information should be backed up by written leaflets. She should be given contact numbers for support groups.
		Posted by S G. Tue Jul 22, 2008 03:09 am
(a) Justify your clinical assessment and investigations [8 marks]. Urinary symptoms are common in the patients of this age group and it affects their quality of life. Previous normal vaginal deliveries might be associated with uterine/ vaginal wall prolapsed. Urinary symptoms are common in postmenopausal patients due to atrophy of urogenital epithelium. Patients with diabetes mellitus are more prone to recurrent infections. Chronic cough might be associated with urinary or urge incontinence. Abdominal examination might reveal a pelvic mass causing pressure symptoms. Speculum examination with reveal atrophic changes or associated prolapsed. Urine dipstix for the presence of leucocytes, nitrites or haematuria might reveal urinary tract infection (UTI) and hence urine for microscopy and culture should be sent. Pelvic ultrasound will show pelvic mass or fibroid associated with pressure symptoms. She might need a cystoscopy based on pelvic scan or presence of haematuria in the urine. (b)What will you tell her about the cause of her symptoms, given that clinical assessment is normal? [2 marks] Atrophy of the urogenital epithelium is a common cause of urinary symptoms in post menopausal patients. (c)Evaluate the non-surgical treatment options [10 marks]. Urine dipstix suggestive of UTI should be treated with antibiotics. Pelvic floor muscle exercise is unlikely to benefit in such patient. In patient with associated uterovaginal prolapse, option of ring or shelf pessary should be given. Option of local hormonal replacement therapy (HRT) for atrophic changes should be given provided there is no contraindication to HRT. Option of anticholinergic medication like Duolexitine can be offered for detrusor overactivity but side effect like dry mouth might be troublesome.
		Posted by Farkhanda A. Wed Jul 23, 2008 05:24 pm
Dear Paul Please can you check my essay before sending essay plan. Thank you