MRCOG/MOG PRACTICE QUESTION 2

QUESTION 2

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

BMI

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.

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

Pelvic floor excercise

PELVIC FLOOR EXCERCISE

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,

Consent Has been Taken from Patient to publish this video ( For Teaching Purpose)

Consent for urogynae pts

  

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:______________