Urogynecology: Evidence-Based Clinical Practice 2nd ed.

3. How to Manage the Patient After History and Examination

Kate H. Moore1

(1)

Department Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia

Abstract

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. Collaboration 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), dietician, or neurologist may be required. If the patient has truncal obesity and cannot lose weight, order tests for serum insulin levels at 0, 1, and 2 h after 75 g glucose load; if she has insulin resistance, metformin therapy is likely to help her lose weight. From a surgical point of view, referral to an ENT surgeon, thyroid surgeon, or colorectal surgeon may be needed. The urogynecologist should treat constipation and atrophic vaginal symptoms.

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. Collaboration 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), dietician, or neurologist may be required. If the patient has truncal obesity and cannot lose weight, order tests for serum insulin levels at 0, 1, and 2 h after 75 g glucose load; if she has insulin resistance, metformin therapy is likely to help her lose weight. From a surgical point of view, referral to an ENT surgeon, thyroid surgeon, or colorectal surgeon may be needed. The urogynecologist should treat constipation and atrophic vaginal symptoms.

As mentioned, if midstream urine dipstick suggests cystitis, this should be treated, as bacterial endotoxins may weaken urethral sphincter strength or exacerbate detrusor contractions; thus, cystitis may worsen incontinence (see Chap. 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 postoperative 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 Chap. 5 for definition of mild, moderate, severe.). If the condition is severe or complex, urodynamic tests will be required, but there may be a waiting time for this, hence the need to start basic continence therapy.

·               If mild stress incontinence and good PFM strength, give home PFM training program, and refer for two to three physiotherapy visits (Chap. 6).

·               If mild stress incontinence but weak PFM strength, refer to physiotherapist for electrostimulation; see patients after 12-week therapy; book urodynamics then if no cure.

·               If severe primary stress incontinence (wants surgery), book urodynamic testing; discuss tension-free vaginal tape or TVT-O briefly (see Chap. 9).

·               If mild urge incontinence (or just OAB syndrome, not wet), start bladder training program (Chap. 7), and consider referral to nurse continence advisor for detailed training.

·               If severe urge incontinence and if long wait for urodynamics tests, give therapeutic trial of anticholinergic drugs, with bladder training (patient to stop drugs 1–3 weeks before test, see Chap. 9). Check whether nocturia is a problem; if so, check the FVC for nocturnal polyuria and/or a history of snoring, which may indicate sleep apnea; if so, refer for sleep studies. Give some anticholinergics at night to start with.

Fourth, if Anal Incontinence Is Present

Consider referral to appropriate physiotherapist if mild (Chap. 8). If severe, consider referral to colorectal surgeon for anorectal testing.

Fifth, if Prolapse Symptoms Are Present

If mild symptoms and mild on examination, consider referral to physiotherapist. 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 Chap. 10). Discuss vaginal ring pessary or surgery as indicated. Ensure postmenopausal 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 (Chap. 11). Consider booking uroflowmetry for next visit, if urodynamic tests are not needed. Make surepostmenopausal lady with recurrent UTI is on Ovestin.

If Suprapubic Pain, with Severe Frequency, Urgency, and Nocturia, Is Present

Consider diagnosis of interstitial cystitis (Chap. 12). Make sure the urine is sterile. Check that the frequency volume chart documents the severity of symptoms. Consider booking a cystoscopy with refill examination ± biopsy.

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,1 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 sympathetic 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 uniformly guaranteed, major improvement is generally likely to occur.

Explanations of UTI and IC are given in Chaps. 11 and 12.

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 Chap. 10).

Footnotes

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1www.pelvicfloorunit.com.au