Thursday, 18 October 2012

PELVIC FLOOR EXERCISE (PFE)




Kegel Exercise
First published in 1948 by Dr. Arnold Kegel, a pelvic floor exercise, more commonly called a Kegel exercise, consists of repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". Dr. Kegel attempted to develop diverse exercise for the injured women’s pelvic muscle due to childbirth or natural urinary incontinence.

Introduction
The aim of Kegel exercises is to improve muscle toneby strengthening the pubococcygeus muscleof the pelvic floor. Kegel is a popular prescribed exercise for pregnant women to prepare the pelvic floorfor physiological stresses of the later stages of pragnancy and childbirth. Kegel exercises are said to be good for treating vaginal prolapse and preventing in women and for treating prostate pain and swelling resulting from benign prostatic hyperplasis (BPH) and prostitis in men. Kegel exercises may be beneficial in treating urinary incontinence in both men and women. Kegel exercises may also increase sexual gratification and aid in reducing prematue ejeculation. There are many actions performed by Kegel muscles include holding in urine and avoiding defecation. Reproducing this type of muscle action can strengthen the Kegel muscles. The action of slowing or stopping the flow of urine may be used as a test of correct pelvic floor exercise technique but should not be practiced as a regular exercise to avoid urinary retention

Indications:
1. Urinary incontinence - The consequences of weakened pelvic floor muscles may include urinary or bowel incontinence, which may be helped by therapeutic strengthening of these muscles. Meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that "PFMT (Pelvic floor muscle training) should be the first-line conservative programs for women with stress, urge, or mixed, urinary incontinence.

2. Pelvic prolapse - The exercises are also often used to help prevent prolapse of pelvic organs. A meta-analysis of rabdomised controlled trials by the Cochrane Collaboration concluded that "(there is now some evidence available indicating a positive effect of PFMT for prolapse symptoms and severity.)''


Steps:
Here’s how to do your Kegels to strengthen your pelvic floor: Lie or sit down, whichever you prefer. You may use a pillow as a wedge under the small of your back if you like.
Find the muscle you identified earlier and clench it, then relax. Clench again, than relax. And so on. One clench-and-relax constitutes a repetition, and both sides of the repetition both the clenching and the unclenching are equally important.
You may find it difficult to do Kegels at first if your muscles are very weak. But each repetition really will increase the strength of the muscles, and in time, doing your Kegels will become easier guaranteed.
1.      Tighten the muscle and hold for 10 seconds, relax for 10 seconds. Do 10 repetitions to strengthen   your slow-twitch pelvic floor muscles.
2.       Tighten and hold for two seconds, relax for two seconds. Do 10 repetitions to strengthen the fast-twitch fiber muscles. The two different basic Kegel exercises differ only in timing, not in the process.

Effect of Kegel Exercise
1. At the last month of pregnancy, the fetus goes down and the head puts pressure upon of the perineal region, which causes a pain. Kegel Exercise helps to mitigate the pain by strengthening the perineal region.
2. In case of training the ability of moving the pelvic floor musclefreely though Kegel exercise during the period of pregnancy, it is possible to put pressure upon the exact region at the time of childbirth. This helps to shorten the childbirth time.
3. At the time of giving birth, it is possible to prevent the tear of perineal region by applying the power to the region slowly. If not Kegel exercise, sudden application of power to the region may cause the tear of weak perineal region.
4. After childbirth, urinary incontinence may be occurred due to the relaxation of muscle under the bladder or the rupture of the nerve cell or muscle. In ordinary time, cough, sneezing or laughing may cause incontinence. Kegel Exercise is useful to settle such problems economically.
5. In case of taking a long time in natural childbirth, the fecal incontinence may be occurred. Kegel Exercise helps to return such the anus muscle to the normal state.
6. With steady exercises, it is possible to strengthen the vaginal muscle and regenerate the injured cell due to childbirth by promoting blood circulation around the vagina.
7. This exercise helps to reduce the risk of hemorrhoids caused by constipation during the period of pregnancy or after childbirth.
8. By recovering the elastic force of the vaginal muscle, which is weakened after childbirth, it helps to increase sexual gratification and feel orgasm intensively.

A study by Cammu et al., comprising a 10-year follow-up of women after pelvic floor muscle exercise for stress incontinence, concluded that when pelvic floor muscle training is initially successful there is a 66% chance that the favorable results will persist for at least 10 years.
The trials suggest that the treatment effect (especially self reported cure/improvement) might be greater in women with stress urinary incontinence participating in a supervised PFMT programme for at least three months. It also seems that the effectiveness of PFMT does not decrease with age: in trials with stress urinary incontinent older women it appeared that results for both primary and secondary outcome.

Conclusion
There is evidence for the widespread recommendation that pelvic floor muscle exercise helps women with all types of urinary incontinence. However, the treatment is most beneficial in women with stress urinary incontinence alone,

Wednesday, 8 August 2012

  

Consent of Patient’s agreement for Urogynaecology & Gynaecological

Investigation, Treatment & Surgery

 

Name:----------------------------------  MRN/IC NO:-----------------------------------------
 Name of proposed procedure:

  • SUBURETHRAL SLING AND CYSTOSCOPY WITH/WITHOUT PELVICFLOOR REPAIR FOR PROLAPSE
  • VAGINAL HYSTERECTOMY WITH/ WITHOUT PELVIC FLOOR REPAIR FOR PROLAPSE
  • VAGINAL OR ABDOMINAL VAULT SUPPORT OPERATION WITH/ WITHOUT PELVIC FLOOR REPAIR
  • OTHER UROGYNAECOLOGY PROCEDURES:____________________________________________________
  • HER GYNAECOLOGICAL PROCEDURES:____________________________________________________
 A. Statement of health profession: I have explained the procedure to the patient. In particular, I have explained

1. The intended benefits:  (tick where applicable)
§  To improve or resolve the symptoms of ‘stress urinary incontinence’ and ‘prolapse‘
§  To remove uterus to overcome uterine related pathalogy
§  Others (please specify) ________________________________________________________

2. Possible serious risks:
§  Damage to the bladder and/or Ureter and/or long term disturbance to the bladder function
inapproximately 2% of cases
§  Damage to bowel in approximately in 1% cases
§  Haemorrhage requiring blodd transfusion  in about 2-3% cases
§  Return to the operating theatre for additional stitches or to control bleeding or for open surgery
§  Pelvic abscess/infection approximately in 1% cases
§  Venous thrombosis or pulmonary embolism  approximately in 1% patients
§  Dyspareunia ( painful sexual intercourse)
§  Failure to achieve the desired results or recurrence of prolapse or urinary incontinence
§  Sling complications eg. Erosions, mesh protrusion in about  0.7%

3.Possible frequently occurring risks:
§  Urinary retention in about 3% of patients, may need excision of the tape if unable to void properly
§  Vaginal bleeding, discharge or infection
§  Frequency of micturition, nocturia and urgency in about 7% of patients
§  Wound infection – up to 15% especially in patients with risk factors
§  Pain, may require analgesics

4. Any extra emergency procedures which may become necessary during the procedure:
§  Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure
§  Removal of ovaries for unsuspected disease during the surgery
§  Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder ,ureter, bowel or major blood vessels in approximately 4%- 8% cases
§  Other procedures (please specify) ___________________

I have explained that in obese women those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the quoted risks may be higher.

I have also discuss the benefits and risks of any available treatments including physiotherapy, ring pressary insertion and also option of no treatment


Signature:_____________________________________             Date:_____________________
DR ARUKU NAIDU MD(UKM) FRCOG(UK) CU(JCU)
Consultant Urogynaecologist


Signature of patient: ____________________________                Date:_____________________

 Patients Name:_________________________________
B. Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way which I believe she can understand.

Signature:_____________________ Name:_______________________________ Date:______________

C. Statement of patient
Please read this form carefully. You must also read the front page carefully which describes the benefits and risks of the proposed treatment. if you have any questions, please ask us as we are here to help you. You have the right to change your mind at any time, including after you signed this form.

1.    I have read the previous sheet and understood the benefits                                       YES             NO
      and the risks of the proposed treatment or surgery                                                                                                                                     
       
2.    I agree to the procedure described by the doctor                                                        YES              NO

3.    I understand that you cannot give me a guarantee that a particular person                 YES             NO  
       will perform the procedure. The person will, however has the
       appropriate experience to perform the surgery.

4.   I understand that I have the opportunity to discuss the details of anaesthesia            YES              NO
      with an anaesthetist before the procedure, unless the urgency of my situation
      prevents this.

5.  I understand that any procedure in addition to those described on this                         YES             NO   
     form will only be carried out if it is necessary to save my life or to prevent serious
     harm(complications) to my health

6.  I have been told about the additional procedures which may become necessary        YES             NO  
     during my treatment

7.  I have been given a patient information leaflet                                                                  YES            NO   

8.  I have listed below procedures which I do not wish to be carried out                              YES            NO
     without further discussion
     ___________________________________________________________________________
    
Signature:_____________________ Name:_________________________ Date:______________

D. Witness
A witness should sign below if she/he has witnessed the patient's signature above. Parents or guardians should sign below behalf of patients under the age if legal consent (18 years and above)

Signature:_____________________ Name:_________________________ Date:______________
Relationship to patient: __________________


E. Confirmation of consent
This section to be completed when the patient admitted for a procedure has sign the form in advance. On behalf of the team treating the patient, I have confirmed with the patient that she has no further questions and wishes the procedure to go ahead.

Signature:_____________________ Name:_________________________ Date:______________

Thursday, 12 July 2012

Drugs In The Management of Incontinence

Drugs commonly used for the management of female urinary incontinence can be categorized into the following categories:-

1.     Drugs for overactive Bladder ( OAB)
2.     Drugs for Hypocontractile Bladder
3.     Drugs for Stress Urinary Incontinence
4.  Drugs Acting Outside The Urinary Tract

1.     Detrusor Overactivity ( OAB)

The mainstay of treatment should be behavioural and pelvic floor therapy. When these therapies are ineffective then pharmacological therapy should be added. These pharmacological therapies include:

Anticholinergic Drugs

The drugs of choice are the antimuscarinic drugs. Drugs that are available in Malaysia are:– oxybutynin 2.5-5mg bd/tds (Ditropan ®), Tolteridine 4mg daily ( Detrusitol ®), Fesoteradine (4 and 8 mg), solifenacin 5-10mg daily ( Vesicare ®), Trospium 20mg ( Spasmolyt ®) and  Propantheline Bromide 15md-30mg bd/tds.

This drugs has side effects of parasympathetic blokage like: the complaint of dry mouth which may lead to the undesirable tendency to drink more. It may also cause drowsiness, tachycardia , constipation  and blurred vision. It is therefore contraindicated in patients with acute angle glaucoma and cardiac arrythmia.
In patients with neurogenic detrusor overactivity (detrusor hyper-reflexia) the dosages of these drugs can be increased till the desired inhibition of detrusor contraction is achieved or until intolerable side effects occur.  In some cases, oxybutynin can also be instilled directly into the bladder (5mg tablet crushed into 30mls of saline, instilled 3 times per day and retained for 30 minutes each time)

Oxybutynin has the advantage that it can be used in children above the ages of 5 but must be used with caution in the elderly and in those with heart disease. Both drugs are contraindicated in pregnancy, with breast feeding, in patients with glaucoma and myasthenia gravis. Toleradine and fesoteradine newer antimuscarinic agents which as efficacious as oxybutynin and higher tolerability rate among patients. 

Other quarternary ammonium compounds with antimuscarinic activities include propantheline (Pro-Banthine ®), emepromium and hyoscyamine (Buscopan®). However these drugs are limited by their unpredictable pharmacokinetics and are not commonly used for detrusor overactivity.


Tricyclic Antidepressants

Tricyclic antidepressants have both anticholinergic and alpha adrenergic effects. These drugs are useful for detrusor overactivity and will at the same time increase the urethral sphincter tone. Their central sedative effect is also an advantage especially in patients who are unduly anxious. Imipramine  (25mg od-tds) is usually used. The dose can be increased by 2.5mg/ week until the desired effects are seen or until intolerable side effects occur. Abrupt cessation of the drug must be avoided because of its rebound tendency. side-effects include hepatic dysfunction, mania, cardivascular events.

Flavoxates

Flavoxates (Genurin®, Urispas ®) has no appreciable anticholinergic effects but has anti spasmodic activity on the smooth muscles of the urogenital tract. They also have local analgesics effects and are suitable for symptomatic relief of symptoms of irritable bladder syndrome ie cystitis. High doses (400mg tds) can be used for detrusor overactivity. Side effects are few but can cause drowsiness and must be used with caution in patients with glaucoma and obstructive uropathy.

Other Drugs

Other drugs that can be used for detrusor hyperactivity include intravesical capsaisin (substance P antagonist), beta adrenalgic agonists (terbutaline), calcium channel blockers (nifedipine : Adalat®) have been reported with limited success. These drugs are best considered as adjunct to first line therapy.

2.     Detrusor Hypocontractility

Poor detrusor contractility leads to high residual volume and can lead to overflow incontinence. Treatment is directed at improving bladder emptying.

Parasympathomimetic Agents

These are the agents of choice for improving detrusor contractions. Bethanechol chloride (Urecholine®) was the main agent of choice but is not available locally. The alternative is the cholinesterase inhibitor Ubretid ®. This drug can be given with an initial loading dose of 5 to 10mg followed by 5 mg every other day. It should not be used in patients with circulatory insufficiency and bronchial asthma.

3.      Stress Urinary Incontinence and Uretheric Sphincter Incompetence

For the management of Urethreric sphincter incompetency and strees urinary incontinence:  pelvic floor exercises, vaginal devices, injectables and  surgery has always been considered the main modality of treatment. However several types of pharmacological agents have been found to be of some benefits. There are alpha adrenalgic receptors on the bladder neck and on the smooth muscle portion of the external urethral spincter and alpha adrenalgic agonists appear to increase the tone of these smooth muscles at the bladder neck. Other pharmacological agents include the Serotonin Norepinephrine Reuptake Inhibitors.

Alpha adrenalgic agonist

Drugs available include epinephrine, pseudoephedrine and phenylpropanolamine. These are commonly found in cough mixtures and nasal decongestants. They should be viewed as adjunct treatment to the other established modalities of treatment for urethric sphincter incompetence.

Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

Duloxetine hydrochloride (Cymbalta ®, Yentreve®) is a drug that primarily targets major depressive disorders and pain related to diabetic peripheral neuropathy. It is now found to be effective in the management of stress urinary incontinence. Using 40mg twice daily, the drug has been proven to reduce incontinence episodes by up to 50% in most individuals. Side effects include nausea, fatigue, dry mouth and insomnia. This drug is not available locally and currently not popular simply because it is expensive and for it's long term usage. Availability of sling ( SUS) operation with good results further retards it's usage.

4.     Drugs Acting Outside The Urinary Tract

Oestrogens

Topical and oral oestrogens have been noted to exert a trophic effect on the uroepithelium of the urethra and trigone. It is therefore useful in the incontinent women when the urethral mucosal seal in defective. It does not appear to have any effect with incontinence secondary to bladder neck hypermobility. oestraogen ( oestradiol valerate 0.5gm biweekly for 2 months does help in older women with urogenital atrophy (UGA)

Anti-diuretic Hormone (ADH)

Desmopressin (Minirin dDAVP®) is a synthetic vasopressin that increases distal renal tubules reabsorbtion of water. It is effective in the treatment of enuresis where a deficiency of nocturnal ADH is present. It is also useful in the elderly patient with nocturia. It can be taken orally in doses of between 0.2 to 0.4mg at night and at these doses, there will be between 8 to 20 hours of antidiuresis. Its use is contraindicated in those patients with unstable angina and cardiac failure.


Dr Aruku Naidu MD FRCOG CU

Sunday, 1 July 2012

What are Urodynamics?




Urodynamics means the study of pressure and flow in the bladder and the tube through which you pass urine, the urethra.  These investigations show what is happening when the bladder is filling and emptying.  If you’ve been booked for urodynamic studies you will have been experiencing bladder or prolapse problems and Dr Aruku has decided that you need to have these tests done to accurately diagnose and determine the treatment options.

When Do You Need Urodynamics?
Not everyone with bladder problems needs urodynamic studies.  They’re most useful where:
·         There may be a mixture of symptoms, or uncertain symptoms
·         Where an operation may be considered and the doctor wants to make sure it is necessary and will be helpful
·         Previous treatment has not improved the problem eg physiotherapy or medication, or
·         After surgery for bladder or prolapse repairs.
Urinary symptoms like incontinence (leakage of urine), frequency, dribbling etc. do not accurately tell the doctor what may be wrong with you.  Urodynamics forms part of a total assessment of your bladder problem and will help us make an accurate diagnosis so that you get the right treatment options explained to you.  It may even avoid unnecessary surgery.  Also it guides the surgeon as to what may happen to your bladder or bowel after surgery.

What is involved?
Please attend with a comfortably full bladder.  When you arrive you’ll be asked to pass urine, in private, into a toilet or commode.  You’ll be asked to change into a dressing gown and lie down on a couch.   The doctor will examine your bladder through a fine scope called a flexible cystoscope.  Then fine hollow tubes will be passed into your vagina and bladder.  These tubes are attached to a chart recorder that monitors the pressure in your bladder and abdomen.
The bladder will gradually be filled with fluid.  You’ll need to indicate to us what sensations you feel eg. Normal desire to pass urine and urgency. During the filling of your bladder you will be asked to cough every so often.  Once the bladder is full we will get you to stand and cough again and do some easy exercises like heel bounces.  After this you’ll be asked to pass urine into a special receptacle, which will record rate of flow of urine.  The staff will usually be able to let you do this in private.  The tubes will then be removed and the procedure is complete.
While the procedure is taking place, the recording device records a graph of what your bladder is doing.  Your test results will be discussed with you by the doctor and treatment options explained.  The procedure should take between 20 and 30 minutes.  Try not to worry –everything will be fully explained to you both before and during the procedure and every effort will be made to ensure a minimum of discomfort and maximum privacy

Do I Need to Prepare for the Investigations?
Yes.  Please attend clinic with a comfortably full bladder.  If you have a urine infection please contact us so that another appointment can be made for you.

Afterwards:

Most people have no problems after the procedure is performed. You should drink plenty of fluids for the remainder of the day.  There will be a small amount of irritation caused by catheters, this should subside in 24-48 hours.  If you do experience burning or stinging when passing urine we suggest you purchase a packet of ural sachets from your local pharmacy. If discomfort persists after 48 hours please contact your local doctor or Dr Aruku’s clinic.

Wednesday, 2 May 2012

TRIP TO DOWN UNDER

In May 2003 JPA (Jabatan Perkhidmatan Awam), offered the first ever scholarship to pursue fellowship in Urogynaecology.  Following few contacts and recommendations, I manage to secure an urogynaecology and pelvic reconstructive surgery fellowship training programme with Professor Ajay Rane a well known professor in urogynaecology from James Cook University (JCU), Townsville, Queensland Australia.

Little is known about JCU and Townsville. My first reaction was to look up in the world atlas and search the wed site, to see where this place is? Townsville is the “capital city” of the northern Queensland, with a population of about 150,000 people along with it twin city Thuringowa, and it make up the largest city in tropical Queensland. Townsville got the name from Sidney businessman Robert Townsville, who sponsored the establishment of a port in 1864.

The excitement turned to horror, especially when I was trying to gain entry into Australia. There are various levels of screening and protocols to follow before getting a visa. It took almost 4 months to obtain entry permission. There are also various levels of bureaucracy in obtaining medical registration with the Queensland medical board.

After the long wait, it was time to travel. The flight took 7 plus hours and further 11/2 hours from Brisbane as Townsville is situated about 1300kms north of Brisbane. Townsville is quite and peaceful town. The weather was extremely hot ranging between 32 to 38 degrees. However the weather became very pleasant between Mac to September (winter months). We (with family) managed to settle down quickly and the training and posting commenced smoothly.

Adapting to the new environment and system did not take very long as the team in the urogynaecology department was very helpful. The real work started after the Christmas and New Year break. The urogynaecology and pelvic reconstructive department in Townsville is the first subspecialist services in the North Queensland and this unit covers a wide area as up to the Northern Territory.  Our referrals are mainly from general practitioners and occasionally from the O & G specialist.
Prof. Rane and this team of one senior lecturer (Dr Christopher Barry), 2 fellows in urogynaecology, and a bladder nurse (Audrey Corstiaans) and other allied staff is well known not only in Australia but also in the world of Urogynaecology as a centre of excellence. The centre carries out various multicentre trials in urogynaecology. It is also the first centre to invent and publish about Perigee, a device invented to correct the anterior wall prolepses using transobturator route. I was lucky to be part of the team when this procedure was introduced and to date numerous abstracts and papers has been published with regards to this product.

The urogynaecology department is a very busy unit, with almost 95% of their work concentrated on incontinence and pelvic reconstruction. We were involved in 3 and half days of Clinics, urodynamics & surgery in both the public (Townsville Hospital) as well as the private hospital (Mater’s Hospital) and Townsville Day surgery Unit. The other days are allocated for research.

There was so much going on at the same time. During my one-year sting, we managed to organize a North Queensland Urogynae and Pelvic reconstructive surgery conference. Prof. Bob Schull a well-known pelvic surgeon attended the conference from Texas, United States. We also carried out nearly 6 trials or studies. Some of the studies are still on going. We also presented few papers in the IUGA/ICS conference in Paris. Apart from that we also published few papers pertaining to urogynaecology. 

Life was hard initially especially with regards to research as being a clinician for so long. As time goes by it has become part of work and it was interesting. There were ample operating opportunities to learn new surgeries in Uogyanecology and pelvic reconstruction.

Training aside, the weekends were completely free and we had great time visited the surrounding areas. Schools are fantastic; children had stress free schooling with minimal exams and homework. Quality of life was certainly fantastic as there was ample time to spend with the family. Townsville has few exciting places to visit; this includes the Billabong Sanctuary, where you can see and play with Australian wide-life.  The Reef Headquarters’, the largest reef aquarium world is in Townsville. The Great Barrier Reef and the Cairns tourist town are only about 350kms north of Townsville.

Work, research and pleasure as an urogynaecology fellow in Townsville/JCU quickly elapse and it was time to set back to the routine and hassle bustle of Malaysian life. The knowledge and experience gained during this short sting is there to stay in my memory for a long time.  I wish l could one day follow the foot steps of my “GURU’ Prof. A Rane, to establish a vibrant and active Urogynae and pelvic reconstructive unit (Pelvic Health Center) in Malaysia.

Back in Malaysia, with the help of Dr Mukudan, head of O & G department. I have the opportunity to start the first Pelvic Health Unit in Ipoh Hospital. The response was tremendous. We can see that there is so much work in urogynaecology and pelvic reconstruction in Perak alone. These poor patients were suffering in silence for so long, no where to turn to or they were provided with substandard advice and treatment. To start with we introduce the Pelvic Health Concept which basically teaches public how to take care the pelvic structures.


Ipoh hospital is the first public hospital to set up the Pelvic Health Unit (urogynaecology and pelvic reconstructive unit) under the department of obstetrics and gynaecology. The first line of management is to educate patients about good bladder habits, such as posture during micturation, avoidance of bladder irritants, pelvic floor exercises and maintenance of good general health. Our unit has started the “Beat The Bladder Blues” campaign to create awareness among care providers and public and how to seek advice with regards to their bladder or prolapse problem.

We in the Pelvic Health Unit, Department of O & G. Ipoh Hospital, welcome your referrals and support. We are contactable at  05-2085089( urogynaecology Clinic, Ipoh Hospital), 05-2408777( Sessional clinic Ipoh specialist hospital) and email: aruku64@yahoo.com.au. aruku1964@gmail.com