Tuesday, 2 April 2013



A 58 year-old woman has had a TAHBSO 3 years earlier for uterine fibroids and now complains of ‘something coming down’ her vagina. Examination reveals a vault prolapse and a moderate cystocoele.

How would you manage her? (Key word here is MANAGE; which would include history, examination, investigation, treatment)

a)      History
Clarify nature of symptoms, worse with standing/ standing, relieved by lying down
Effects on quality of life
Urinary symptoms- any incontinence, incomplete voiding, voiding difficulties (symptoms likely to be related to prolapse)
Bowel symptoms- incontinence, difficulty emptying rectum (URINARY AND BOWEL symptoms comes hand in hand)
Sexual history and desire to retain sexual function
Previous gynecological history especially on the hysterectomy/ prolapse surgery

b)      Examination
Any abdominal mass
Speculum examination; using the objective assessment of prolapse with POP-Q
Access for SUI after reducing prolapse with full bladder
Pelvic examination (the Bimanual- to assess for pelvic mass)

c)      Investigations
Relevant blood investigations eg FBC, Renal Profile, pre-operative work up

d)     Treatment options
Non-surgical options
-Pelvic floor exercise – no evidence for efficacy, used in women whom wants to avoid surgery but maintain sexual function, unlikely to be effective
- Pessaries- ring/shelf (with the ring, likely to be expelled in women with deficient perineum/perineal body. With shelf pessary, sexual intercourse may not be possible). Should be reserved for women who are unfit/decline surgery or while awaiting surgery. Need to be changed every 6-9 months.

Surgical options
-          Abdominal sacro-colpopexy- effective, evidence proven, major surgery for a relatively healthy women but may require the additional vaginal procedure if woman has anterior/posterior vaginal wall prolapse
-          Sacrospinous ligament fixation – vaginal procedure with lower morbidity and suitable for women who are unfit for laparotomy. Failure rate higher than abdominal route. Allows simultaneous vaginal wall repair.
-          Laparoscopic sacro-colpopexy may be undertaken if expertise is available
-          Colpocleisis may be offered for frail women who do not wish to retain sexual function.
-          Mesh- controversial and probably should not be mentioned in an exam answer as the only evidence for it would be anterior repair.



A 65 year old otherwise healthy woman presents with incontinence of urine on coughing, sneezing and laughing.
a)What important aspects in history will influence your subsequent management? 8 marks

b)What investigations would you perform and how would you manage her?12 Marks

-severity of incontinence and the impact on quality of life (QOL)*IMPORTANT
-other urinary symptoms; urgency, urge urinary incontinence, frequency, nocturia
-symptoms of voiding dysfunction; dribbling, hesitancy, poor stream, strain to void
-UTI symptoms; dysuria, haematuria, frequency
-Presence of bladder pain and prolapse symptoms
-Bowel symptoms- constipation, incontinence of faeces
-Past obstetric history including date of last delivery and reproductive intentions
-Fluid intake, caffeine, alcohol
-Previous treatment for incontinence including surgery

Key point here is ‘healthy woman’
Urine dipstick
Mid stream urine for culture
Bladder diary/ Frequency volume chart
Multichannel urodynamics only if conservative treatment has failed or if surgery is being considered or before surgery if there is clinical suspicion of DO/ previous surgery for SUI or anterior compartment prolapse/ symptoms of voiding dysfunction

Management include an examination (BMI, abdominal and pelvic examination; pelvic mass, palpable bladder; Check for presence of prolapse; Demonstrate SUI with moderately full bladder, 150mls)
  • Life style intervention: reduce weight, quit smoking, reduce/avoid risk factors, control medical disorders like asthma
  • Application of oestrogen cream/gels-controversial, there are some evidence that has shown , reduction in all type of incontinece
  • First line treatment should be supervised pelvic floor exercise/ muscle training (PFMT) lasting at least 3 months, there good evidence shown significant reduction in the incontinence esp. GSI ( 65-70%)

  • Duloxetine should not be used as first line treatment or should not be routinely used as a second-line treatment for SUI. (NICE guidelines)

Surgical options if conservative treatment failed;
-          retropubic mid-urethral tape ( Subject. & Object cure rate 85-95%)
-          open colposuspension (Subject. & Object cure rate 85-95%)
-          TOT
-          Intramural bulking agents
-          Artificial urinary sphincter
Not recommended for SUI;
-          Routine use of lap colposuspension
-          Anterior colporrhapy, needle suspensions, paravaginal defect repair, MMK procedure
-          Autologous fat and PTFE as intramural bulking agents