Chapter 3
How to Manage the Patient After History and Examination
First,Treat Precipitating Factors
The complete management of incontinence and prolapse is not just a surgical exercise! You need to think about the patient’s medical problems as they relate to their pelvic floor problem. Col- laboration with physicians and other surgeons may be needed.
From a medical point of view, referral to a respiratory physician, endocrinologist (for hypothyroid-related obesity, diabetes), dieti- cian, or neurologist may be required. From a surgical point of view, referral to an ENT surgeon, thyroid surgeon, or colorectal surgeon may be needed. The urogynecologist should treat con- stipation and atrophic vaginal symptoms.
All patients should have a midstream urine cultured to exclude cystitis as a confounding variable/factor that is likely to worsen incontinence (see Chapter 11).
Second, Obtain all Relevant Old Notes
Previous continence surgery needs to be precisely documented, so that you can assess the likelihood of “natural failure” of the procedure, or the risk of post-operative voiding difficulty that may not be symptomatic.
Any previous major abdominal surgery needs to be clarified, especially radical surgery for malignancy, as this may disturb the local innervation, or relays between the sympathetic and parasympathetic nerves in the pelvis, leading to complex incontinence.
Third, Begin a Basic Management Program for Urinary Incontinence
If the condition is mild, this may be curative (see Chapter 5 for definition of mild etc). If the condition is severe or complex, uro-
dynamic tests will be required, but there may be a waiting time for this, hence the need to start basic continence therapy.
䊏 If mild stress incontinence and good PFM strength, give home PFM training program (Chapter 6).
䊏 If mild stress incontinence but weak PFM strength, refer to physiotherapist for electrostimulation; see patients after 12 weeks therapy, book urodynamics then if no cure.
䊏 If severe primary stress incontinence (wants surgery) book urodynamic testing; discuss Tension-Free Vaginal Tape briefly.
䊏 If mild urge incontinence (or just OAB syndrome, not wet) start bladder training program (Chapter 7) and consider refer- ral to nurse continence advisor for detailed training.
䊏 If severe urge incontinence and if long wait for urodynamics tests, give therapeutic trial of anticholinergic drugs, with bladder training (patient to stop drugs one week before test).
Fourth, If Anal Incontinence Is Present
Consider referral to appropriate physiotherapist if mild (Chapter 8). If severe, consider referral to colorectal surgeon for anorec- tal testing.
Fifth, If Prolapse Symptoms Are Present
If mild symptoms and on examination, consider referral to phys- iotherapist. Treatment of precipitating factors can make cure much more likely. If there is a moderate or severe prolapse, assess suitability for surgery and patient’s wishes (see Chapter 10).
Discuss vaginal ring pessary or surgery as indicated. Ensure post- menopausal women are given topical estrogens prior to ring or surgery.
If Associated Recurrent Bacterial Cystitis (Urinary Tract Infection, UTI) Is Present
Obtain old MSU results where possible to check for proven UTI.
Order renal ultrasound and post-void residual measurement (Chapter 11). Consider booking uroflowmetry for next visit, if urodynamic tests not needed.
If Suprapubic Pain, with Severe Frequency, Urgency, and Nocturia Is Present
Consider diagnosis of interstitial cystitis (Chapter 12). Make sure the urine is sterile. Check that the frequency volume chart doc- uments the severity of symptoms. Consider booking a cystoscopy with refill examination +/− biopsy.
3. HOW TO MANAGE THE PATIENT AFTER HISTORY AND EXAMINATION 23
A FEW WORDS ABOUT EXPLAINING THE SITUATION TO THE PATIENT
Urinary Incontinence
Most patients have little idea that there are different kinds of leakage. We find it helpful to give out a short booklet explaining this at the end of the first visit, which describes the symptoms, underlying causes, and treatments of stress, urge, and overflow incontinence. It is very helpful to explain that, using a step-by- step approach, most urinary incontinence is largely curable, but that it will not happen overnight. You need to be very sympa- thetic during this explanation, emphasizing how common the problem is (10% of all women under age 65, 25% of women over age 65, and 30% of women who have recently delivered a baby), so that the patient realizes she is not alone in her problem.
Anal Incontinence
Almost all patients with this problem are deeply embarrassed.
Again, it is helpful to explain that there are different causes for this condition; treatment needs to be according to the cause and thus investigation is very helpful. Although cure is not as uni- formly guaranteed, major improvement is generally likely to occur.
Prolapse
Many patients have little idea of their anatomy, which walls/organs may be involved in prolapse, and that severity of each one does vary. We find it extremely helpful to draw a diagram for the patient, illustrating her particular problem, and showing her degree of severity. If surgery is indicated/desired, the relevant procedures should also be sketched simply on the diagram (see Chapter 10).
Explanations of UTI and IC are given in Chapters 11 and 12.
24 UROGYNECOLOGY: EVIDENCE-BASED CLINICAL PRACTICE
