MRCOG/MOG PRACTICE QUESTIONS 2013

QUESTION 1.

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

a)

History

-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

b)

Key point here is ‘healthy woman’

Investigations

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)

Conservative

• 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