In the name of ALLAH GB

DR / GHADA BADRAN

mrcog tutor

UROGYNAECOLOGY PROBLEMS
and
pelvic floor problems

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Task 1 Simulated patient task
Candidate instruction

This is simulated patient task to assess the following domains:

** Patient safety
** information gathering
**applied knowledge.
**communication with patient
**communication with colleagues.
You are an ST5 in the ward today, during morning round an ST2
Informed you that there is Patient Liza marten a 48-years-old para 4
this is day 1 Post laparoscopic total abdominal
Hysterectomy and bilateral Salpingo oophorectomy.for heavy vaginal bleeding.
She complained of heavy vaginal
Ultrasound showed multiple fibroid.
For which Laparoscopic total abdominal hysterectomy and bilateral
Salpingo-ophrectomy done yesterday. Patient has severe pain over the night.
ST2 examined patient abdomen and he saw a large swelling in the abdominal wall about
(15x7cm) with wound oozing Blood in anterior abdominal wall after removal
The cover over the incision. Hb before operation 12 now 9
Blood pressure 120\60 pluse rise from 70 to 105 T 38
treatment she is taking
Non-steroidal anti-inflammatory 75 mg IM every 12 hours for 2 days.
Clexane 20 mg subcutaneous once daily for 7 days.
Patient is waiting you as she what to know what is the reason of this swelling.

You have 10 minutes in which you should:

Obtain relevant history.
Address patient concern.
Formulate management plan
 (hello IM DR ……one of the doctors in the ward today can I confirm your name and age please
(what I understand that you have key whole surgery yesterday to remove your womb and ovaries and you complaint of tummy pain and swellling……is this
right…….………)
what is your expectation and concern from today consultation
before coming to your concern shall I ask you a couple of questions at any point if you find yourself you want to ask any question please don’t hesitate to ask
me………………;

Current history can you tell me more about your complaint…….swelling when start …….increasing ………site ……size…pain……do you want analgesia………dizziness
…..fainting ……. fever …..vomiting …… suture line any discharge from the wound…….bowel……bladder… did you start to eat or drink….…did you walk after
operation……chest pain …tightness……leg pain…….……. ……..can you tell me for what reason of operation…….

I will need to examine you in presence of chaperone if you don’t mind

We need to act fast now continuous monitor for your blood pressure ,oxygen and pulse and take blood or investigation and give you IV fluids and insert catheter now
Right now you need in bed don’t move till confirm that you are in stable condition as suspect you have bleeding inside your tummy

Few q more

MEDICAL DISEASE OTHER WISE YOU ARE FIT AND WELL . No any history of blood clot ……. family history of clot
SURGICAL ; DO YOU HAD ANY SURGERY IN YOUR TUMMARY OR PELVIS OR FROM DOWN BELOW
DRUGS DO YOU USE ANY DRUGES BEFORE …..
DRUG ALLEGY DO YOU HAVE ANY Drug ALLERGY
thanks a lot for sharing your information with me
do you want to add any additional information coming to your concern

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Haematoma is a bruise or collection of blood underneath the skin.
superficial haematoma underneath the skin can be expressed especially if there is an opening in the wound.
If the haematoma is increasing in size this is lead to pain, evacuation of haematoma has to be done under anaesthesia.
bleeding vessel that needs to be ligated. I suspect it s the inferior epigastric artery which could injuried during insertion of trocers of laparoscopy
as you are hemodynamically unstable, laparotomy to ligate the vessels should be undertaken without delay
MDT consultant anaethisitis I will inform him about that you take blood thinning agent –nurses of ward – talk to blood bank prepare blood if you don’t
objection of blood transfusion.
Stop blood thinning agent as this increase bleeding……… stop brufen……
Send blood FBC blood to check if your blood coagulate well no – urine and blood to check if there is infection –chest Xray
2 cannula drip in your eye for Fluids paracetamole
antibiotic high dose
catheter to check fluids and urine
Us can help detect if where the site of bleeding
Ultrasound scans will be done one to check superficial layer to check extension of this Collection of blood large in layers of her tummy……….…
and other scan for intra-Abdominal scan to confirm no abdominal bleeding.
Special scan CT urogram to confirm no any injury of other organ.
This is most properly occur due to injury to big vessels called inferior epigastric artery below
The muscle of the tummy this can occur with insertion of the trocar of the laparoscopy and may be not recognised and can appear late after the operation.

Open your tummy consent possibility of injury of internal organs……. May be superficial collection of blood or inside tummy
Possibility of put drain
HDU
Will need prolonged hospital admission.
Blood thing agent can be started 6 h after operation if any no more risk of bleeding
After operation will talk to you to inform you what was the reason
Duty of condor
Incidence report to see to why this one happen.
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 Urodynamic GB

is a study that assesses the bladder and urethra perform their job of
storing and releasing urine it include (cystometery - uroflometery -
complex urodynamic-video urodynamic -ambulatory urodynamic
urethral pressure profilometery)

Incontinence involuntary loss of urine which is objectively

demonstrable and a social or hygiene problem

urinary incontinence types;

1- stress incontinence (commonest type)
2 - mixed incontinence
3 - urge incontinence

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 GB

how is it done patient void catheter inserted (12 F) in bladder one to fill the bladder any residual urine
should be recorded

one transducers inserted to the bladder to measure intra-vesicle pressure another transducers into the
rectum to measure intra-abdominal pressure (while coughing or straining) and both transducer are
connected to recording machine

detrusor muscle pressure calculated by; per-vesical pressure – per-abdominal pressure = (…….)

fill bladder by 100ml \min warm saline while patient sitting on a commode that recording leakage
during this patient should asked to inform when she start to feel bladder filling sensation and strong
desire to void when urgency reported and bladder capacity reached stop filling you ask her to cough
before voiding into flowmeter while the pressure catheters remain in place.

Precautions

stop any medications for incontinence at least 5 days before the test

treat any constipation before test as this could affect result .

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Parts of normal Cytometer :

GB
1) Filling phase 2)voiding phase.
Filling:
1- normal cytometer residual no more than 50 ml
2 - first sensation more than 150 ml (150-200 ml)
3 - desire to void bladder capacity 400 ml or more detrusor muscle normal.
strong desire to void bladder capacity is 600 ml (bladder capacity 400-600ml)
4 - detrusor muscle no contraction during filling phase or single and no more than
15 cm H2O(in case of detrusor overactivity if contraction reach 15 cm \h2o at any
time during filling or frequent contraction reach 5 cm h2o )
5 - no leakage during filling phase
Voiding:
Pressure detrusor 60-70 cm H2O
Bell shaped uroflowmetry with peak flow rate more than 15 ml/sec
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 when you have chart on the exam look to

1 - first voiding sensation GB

2 - bladder capacity

3 - strong urge

4 - leakage where occur

5 - abdominal pressure raised where

6 - vesical pressure raised or no
7 - detrusor pressure

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 indication of urodynamic testing GB

* Do not perform multichannel filling and voiding cystometry before primary surgery if stress urinary incontinence or stress-
predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary
incontinence at examination.

*After undertaking a detailed clinical history and examination, perform multichannel filling and voiding
cystometry before surgery for urinary incontinence in women who have any of the following:

1) urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear
2) symptoms suggestive of voiding dysfunction
3) anterior or apical prolapse
4) a history of previous surgery for stress urinary incontinence.

* be careful urodynamic not recommended before surgery in women with pure SUI or stress predominant incontinence.

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leak

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leak

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leak

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TASK 1 GB

A 49-year-old woman has urinary incontinence.

What would you want to know in the history?
What is the investigation you will do?
Urodynamic done show a mixed picture of incontinence.
What is your advice and initial management?
Later during investigation us scan show a 20-week size fibroid uterus. What do
you suggest?

Information's gathering.
Patient safety.
Communication with colleagues.
Applied clinical knowledge.

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a) INCONTIENCE history • gynaecology history

continuous (fistula ) or interrupted she felt urge to pass urine if she is wetting herself • LMP menopausal or no
before reach bathroom if she is strain during passing urine or
felt incomplete evacuation of her bladder if she leak with cough or strain . • obstetric history
2) she have similar problem before …………….is this affect her life .
• mode of the delivery CS VD instrument delivary which type
3) pain during her water work how many time she pass urine on the day time or at ventouse forceps fetal weight spinal or epidural anaesthesia
night time (in overactive)…….fever ……..
• Medical history
bladder patient void more than 8 times per day and more than one at night )
4) there is any colour chance in urine like presence of blood • (neurological disease –bronchial asthma-DM-chronic cough-chronic
constipation)
5) she is sexual active or no ……..any leak with sexual intercourse.
• surgical history
b)Precipitating factors
has any disease chronic cough ………. Constipation (and bowel incontinence ……… )
• drug history (diuretic)

6) any bulge from down below as kink of the urethra may occur due to prolapse . • drug allergy contraception ; (contraception-HRT)
7) history of any abdominal mass? Fibroid in details …
any abdominal pain …any irregular vaginal bleeding …..bleeding in-between her • cervical smear up-to-date
period ……
• social history smoking alcohol caffeine support at home
8)any vaginal discharge…
• her occupational lifting heavy used before things support at home.
c)Treatment
9)what about pelvic floor exercise it was supervised or no • a family history of incontinence

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examination
in the presence of chaperone after patient permission
vitals blood pressure pulse temperature (no fever ) BMI GB

Abdomen…..any swelling vaginal any prolapse…….any urine leak………

the main investigation :
1) urine dipstick for infection detect the presence of blood, glucose, protein,
leucocytes and nitrites in the urine and culture and sensitivity to exclude infection
Prescribe an appropriate course of antibiotic treatment pending culture results.
2) bladder diary minimum 3 days of the diary covering variations in their usual
activities minimum such as both working and leisure days.
3) blood sugar to exclude DM
4) post void volume in case incomplete emptying
5) us to exclude abdominal masses

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 Bladder diary GB

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Mixed incontinence I will inform her about the diagnose and check wish problem more
bothering the patient and affect her life.If stress incontinence is the predominant symptom in
mixed UI, discuss with the woman the benefit of conservative management including OAB
drugs before offering surgery.
advice her for bladder training and pelvic floor exercise GB
life style modification weight loss if obese stop smoking stop alcohol treatment any cough or
constipation
limit fluids to 1.5 litres per day
if fail urge incontinence will be first medical treatment
Scan show 20 w fibroid cause any symptoms like bleeding pressure symptoms
myomectomy can be option as patient has urinary symptoms
patient should informed even if myomectomy done this may improve frequency but will not
improve her urgency so not think that removal of the fibroid will resolve the problem of
incontinence. urology review before the operation
kidney us and urea and electrolytes should be done to confirm not affected by fibroid exclude
underlying pathology (uterine cervical cancer )
(all treatment options should be discussed myomectomy with GNRH injection before
operation to decrease bleeding uterine artery embolization up to hysterectomy should be
discussed in details risks and benefit )
during surgery should be precaution for avoid ureteric injury like ureteric stent if disturbed
anatomy expected.

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 GB

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Task 2
GB

What is the urodynamic diagnose in the cystometery ?

What are the main treatment for this condition ?
What is the mode of action of anticholinergic drugs ?
What is side effect anticholinergic? And contraindications ?

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 Bladder training
Offer bladder training lasting for a minimum GB
of 6 weeks as first-line treatment to women
with urgency or mixed UI.
When patient feel urgency ever 30 minutes
instruct her to hold herself for 10 minutes or
less as she can before going to the toilet for
a week .
This will allow your bladder to stretch a
little. Continue to hold on for short periods
of time.
Increase time to 15 minutes minutes for
next week. Then 30 minutes ,ect.
Over time, your bladder will stretch and be
able to comfortably hold larger amounts of
urine without discomfort. Until she able to
hold herself for 3-4 hours

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life style modification
GB
bladder retraining Offer bladder training lasting for a minimum of
6weeks as first-line treatment Medication Offer referral to secondary care if the woman does not want
to try another drug, but would like to consider further treatment.
Mirabegron ( Betmiga )
anticholinergic medications Before OAB drug treatment starts, Beta-3-adenoceptor agonist causing the bladder to relax which helps to
discuss with women: fill and also store urine
the likelihood of success and associated common adverse effects and Dose recommended 50mg (25mg if there is renal or hepatic impairment
the frequency and route of administration and ) is recommended as an option for treating the symptoms of overactive
and that some adverse effects such as dry mouth and constipation , bladder only for people in whom antimuscarinic drugs are
blurred of vision drowsiness may indicate that treatment is starting contraindicated or clinically ineffective, or have unacceptable side
to have an effect and that they may not see the full benefits until effects.
they have been taking the treatment for 4weeks.
that the long-term effects of anticholinergic medicines for overactive The use of desmopressin may be considered specifically to reduce
bladder on cognitive function are uncertain nocturia in women with urinary incontinence or overactive bladder who
oxybutynin (immediate release) Do not offer oxybutynin (immediate find it a troublesome symptom.
release) to frail older women who may be at higher risk of a sudden Use particular caution in women with cystic fibrosis and avoid in those
deterioration in their physical or mental health . over 65 years with cardiovascular disease or hypertension.
Or tolterodine (immediate release)or darifenacin (once daily
preparation) Prescribe the lowest recommended dose when starting Do not offer systemic hormone replacement therapy to treat urinary
a new OAB drug treatment. incontinence.
If effective and well-tolerated, do not change the dose or drug.
Offer intravaginal oestrogens to treat overactive bladder symptoms in
Offer a transdermal OAB drug to women unable to tolerate oral
postmenopausal women with vaginal atrophy.

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Offer a further face-to-face or telephone review if a woman's condition stops responding optimally to treatment after an initial successful 4-week review.
Review women who remain on long-term drug treatment for UI or OAB annually in primary care (12 months or every 6months for women over 75). Invasive procedures for GB
overactive bladder
• For women with overactive bladder that has not responded to non-surgical management or treatment with medicine and who wish to discuss further treatment options:
• offer urodynamic investigation to determine whether detrusor over activity is causing her overactive bladder symptoms and
• if detrusor over activity is causing her overactive bladder symptoms, offer an invasive procedure in line with recommendations to or
• if there is no detrusor overactivity, seek advice on further management from the local MDT in line with recommendation.
• If the first treatment for OAB or mixed UI is not effective or well-tolerated, offer another drug
Consider treatment with botulinum toxin type A after a local MDT review
After a local MDT review, discuss the benefits and risks of treatment with botulinum toxin type A with the woman and
explain: the likelihood of complete or partial symptom relief-the process of clean intermittent catheterisation, the risks,
and how long it might need to be continued-the risk of adverse effects, including an increased risk of urinary tract
Infection.
Use 100 units as the initial dose of botulinum toxin type A to treat overactive bladder in women.
Offer a face-to-face or telephone review within 12 weeks of the first treatment with botulinum toxin type to assess the response to treatment and adverse effects, and:
if there is good symptom relief, tell the woman how to self-refer for prompt specialist review if symptoms return, and offer repeat treatment as necessary
if there is inadequate symptom relief, consider increasing subsequent doses of botulinum toxin type A to 200 units and
review within 12 weeks if there was no effect, discuss with the local MDT.
If symptom relief has been adequate after injection of 100 units of botulinum toxin type A but has lasted for less than
6 months, consider increasing subsequent doses of botulinum toxin type A to 200 units and review within 12 weeks.
Do not offer botulinum toxin type B to women with overactive bladder.

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 GB

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 GB

Percutaneous sacral nerve stimulation

A procedure used to treat overactive bladder.
A device is implanted in the back usually at S3 to stimulate the nerves at the base
of the spine. These nerves affect the bladder and surrounding muscles.
Percutaneous posterior tibial nerve stimulation
A procedure used to treat overactive bladder.
A mild electric current is passed through a fine needle to stimulate a nerve in the
leg. This nerve controls bladder function.

Contraindication in patient with pacemaker

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 GB
Augmentation cystoplasty
Discuss the small risk of malignancy occurring in the
augmented bladder.
Provide life-long follow-up.
Surgical approaches include bladder augmentation or ileal
conduit (urinary diversion).

Augmentation cystoplasty involves implanting a segment of

the woman’s own ileum into the bladder with the aim of
increasing bladder capacity.

Specific complications include bladder rupture, intestinal

obstruction, adhesion formation, leakage from the
bowel/bladder anastamosis, abscess and fistula formation.
The link between this procedure and malignant changes is as
yet unsubstantiated.

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 Urinary diversion GB

Provide life-long follow-up.

Urinary diversion involves implanting the ureters into a
segment of the ileum attached to its vascular pedicle, forming
a urostomy on the surface of the skin.

Total cystectomy may be indicated with this procedure in

women with significant postoperative bladder pain.

The complications of urostomy include fluid and electrolyte

disturbances (metabolic alkalosis), renal stones, renal failure,
ischaemia of the ileum and ureteric stricture.

However, balancing these with the previously debilitating

consequences of overactive bladder syndrome means that
patients have a substantially improved quality of life.

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Mode of action of anticholinergic drugs
antimuscarinic drugs block the action of acetylcholine (acetylcholine cause invoulantary muscle movements in the GB
bladder mainly the muscarinic acetylcholine receptors )
Inhibit release of acetylcholine at the nerve endings in dertrusor muscle lead to smooth muscle relaxation
side effects
dry mouth
blurred of vision
dry eyes
constipation
urine retention
Contraindication of antimuscarinic drugs
mythenia gravis
glaucoma
ulcerative colitis
cardiac patient
Hyperthyroidism
pregnancy

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TASK 3
GB
This is a structured discussion task assessing:

The examiner is going to discuss with you a case of primiparous lady who gave birth for 4.2kg baby, assisted with Forceps.
She was on epidural during labour.urinary catheter was inserted after delivery, removed before 6h but the woman failed to pass urine.

1) Tell me what you know about this patient and what is your immediate action(first)?

2) what are the risk factors for the development of postpartum voiding dysfunction?

3)What is the examination you will do for her ?

4)what type of catheter?

4) What are you going to do if volume drained was 600 ml for how long to keep catheter?

5) She still unable to pass urine (after the duration you mention)for how long to keep catheter?

6)What to do if still having voiding difficulty by that time?

7)what you will do if there is haematoma ?

8)What are the possible implications in the future and symptoms she could have ?

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• Urine retention failure to pass urine within 6 hours of vaginal delivary or catheter removal should recognised early and treated
• Details history about her complaint when she start to complaint History of same problem before any history of prolapse
• go through her notes parity sponteous or induced delivery any urinary tract infection , if catheter
• `remove when woman is mobile.
• epidural spinal anaesthesia prolonged labour (first –second stage) shoulder dystocia
• perineal trauma or stiches pain or haematoma is catheter removed before apply forceps or no
• manual removal placenta any pack inserted bleeding blood transfusion any comorbidities. Any drug allergy
• first void time and amount colour pain
• review her meow chart fluids intake Output
• examination chaperone patient consent vitals abdominal any palpable full bladder
• vaginal examination any swelling or vulval haematoma any leakage any missed vaginal pack prolapse
• catheter using an aseptic technique assess risk of thrombosis
• It is recommended to use the smallest size; for women (for example 12–14 Ch)
• if no void for 6 hours and patient bladder volume more than 500 ml insert indwelling catheter for 24 hours if post resudual volume more than 150 ml
• keep catheter for 1 week if persist more reassurance and refer to urology opinion and teach clean intermittent self catheterization
• what you will do if there is haematoma ? Explain diagnose to patient consent examination under anaesthesia antibiotic after confirm no drug allergy
evacuation
• and haemostasis catheter and pack at least for 24 h document assessment of thrombosis documentation incidence report .
• symptom chronic urinary tract infection incontinence of urine
• collect urine for culture and sensitivity US for post voiding residue
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The aim of intra-partum bladder care is to prevent bladder over-distension.
Following delivery or catheter removal, no woman should be allowed to go longer than 6 hours without voiding.

If postpartum voiding dysfunction is unrecognised, it can lead to bladder underactivity and prolonged voiding dysfunction, with
sequelae such as recurrent urinary tract infection and incontinence
Many risk factors have been identified for the development of postpartum voiding dysfunction, including :
• • prim parity
• • instrumental delivery
• • epidural analgesia
• • prolonged labour
• • perineal trauma.
• pidural anaesthesia can affect bladder sensation and, therefore, it may be appropriate to leave an indwelling catheter in place for
a longer period following delivery.
• the catheter is deflated or removed during active pushing and delivery to prevent the theoretical risk of bladder trauma.
• If a catheter remains in situ following an instrumental delivery, manual removal of the placenta or repair of a third‐degree tear,
the catheter should not be removed until the woman is mobile and careful attention should be paid to voiding within the
following 6 hours.

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 Following the diagnosis of urinary retention, a urine sample should be analysed and sent for culture, as the presence of
infection can contribute to and prolong voiding dysfunction. If a urinary tract infection is suspected, prompt antibiotic
treatment is required.
The perineum should be examined and, if swollen or painful, a catheter should be sited until the swelling and pain have settled.
• Adequate analgesia is important, as perineal pain is a significant factor in the development of retention.
• Constipation should be avoided and treatment given if required.
• Upon catheter removal, the voided volume and post void residual urine volume must be recorded.
• The catheter material is not important for short‐term catheterisation, except in the presence of latex allergy.
• The catheter should be inflated with a maximum of 10 ml of sterile water .
• Voiding dysfunction after this period requires careful assessment, including a neurological examination, and is treated by
intermittent self catheterisation.

• Possible future complications?

• Possible long term complications ?
• voiding difficulties.
• recurrent UTI
• Pyelonephritis
• Urine retention with over flow incontinence
• Affect of kidney function tests.

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 Neurological injuries related to obstetric anaesthesia
Given the potential for greater trauma, nerve injuries are more common with epidural than
spinal anaesthesia.

The most common anaesthetic-related injury is traumatic injury to the spinal cord, conus
medullaris or the nerve roots because of accidental damage during insertion of the
spinal/epidural needle. Trauma results in pain, paraesthesia, anaesthesia and weakness in the
distribution of the affected nerve root.

Rare but devastating complications include vertebral canal haematoma and abscess formation.
Haematomata may occur when the anaesthetic needle or catheter damages the epidural venous
plexus. They present early as the expanding haematoma compresses nerve fibres within the
vertebral canal. Epidural abscesses result from the introduction of pathogens into the epidural
space. Abscesses take time to develop so tend to present later. Both of these scenarios are rare
with careful practice, including attention to coagulopathies, timing of anticoagulation therapy
and scrupulous asepsis. By compressing the spinal cord/cauda equina and spinal nerves, they
present with back pain and tenderness and bilateral sensory, motor and autonomic symptoms,
including anal and bladder sphincter involvement and paraplegia, which may be permanent.

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TASK 4

a simulated patient task assessing:

a lady P2 was referred FROM HER GP with a “lump in her vagina”simple
CYSTIC LESION no change in colour in the anterior vaginal wall.
3 cm for 3 months and become painful for 3 weeks AND WANT INCISION
will seen by the consultant but consultant is away and busy and ask you to
see patient ..

INFORMATIONS GATHERING
PATIENT SAFTY
APPLIED KNOWLEDGE
COMMUNICATION WITH THE COLLEGUES

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 GB
• Introduction apologize that consultant not around if you would like me to continue the consultation with you
• I have gone through your notes expectation and concern
• I will need to ask you a couples of questions at any point you find any thing not clear don’t hesitate to ask me well organised history (start with open question)
• main points in the history current complaint:
• can you tell me about your complaint………………
• when you start to have this complaint……………….
• (dysuria) pain with urination …….fever…… recurrent URT (last was one month)……..vaginal discharge…….
• (dyspareunia) pain with sexual intercourse …or affect her sexual intercourse…incontinence ……….blood in her urine …………bowel symptoms ………….. If she try any
treatment before or no
• (Dripping )post voiding dripping (the role player tell the cyst is increasing im afraid it will be cancer what I have )
• gynaecology history can you tell me about your period………………when the last menstrual periods
• obstetric history have you ever been pregnant before when the last delivery
• Medical history surgical history
• drug history drug allergy
• contraception ; (recent contraception) cervical smear
• social history
• do you smoke do you drink alcohol do you use any recreation drugs
• what do you do for living lifting heavy things
• ( partner support …….did you have enough support at home family history
• thanks a lot for sharing your information's with me
• do you want to add any additional information's
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• Examination chaperone after your permission GB
• why you refuse examination any specific concern about this ?...... examination will keep your dignity as examination is very important, can give
us valuable information what could be possible diagnose. if you still refuse examination we can just have look by separating 2 labia just to give idea ………
• To confirm what could be the reason for this bulge we need to examine you as there is different reason for this plug
• DD its very unlikely to be sinister cyst
• prolapse(cystocele) weakness in the anterior vaginal wall
• vaginal cyst, mass
• urethral diverticulum(is a pocket or out pouching that forms next to your urethral pipe lead to fills with urine when bladder empty and causes symptoms
• Gartner duct cyst
• Bartholin cyst
• MDT include my consultant Urology in your management
• urine for culture and sensitivity treat with antibiotics if there is infections
• special scans like double balloon urthrogrma MRI vaginal ultrasound scan
• urodynamic cystoscopy urthroscopy micturition cystogram
• treatment conservative treatment ..antibiotics
• urology (he will be the one who will do operation for you)
• will discuss with your different surgical treatment for removing this pouch
• which can be removed through your frontal passage(transvaginal marsuplisation)
• or through your urethral pip (endoscopic reroofing)which we are going to widethe neck
• of diverticulum and this lead to drainage of the fluids on it operation will done after your consent.

• discuss risk of operation anaesthesia complications bleeding urinary incontinence infection fisula

• appointment for examination and further counsel with consultant

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 GB

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 TASK 5
Simulated patient task with lay man examiner
Candidate instructions:
This is simulated patient task will assess the following domains:
Information gathering
Communication with patient
Patient safety
Applied clinical knowledge
You are an ST5 about to see Liza marvel a 48 –year-old lady p2
with a feel of “lump down there”.
A picture given .
BMI was 37, she was smoker 2o cigarettes .
She come to discuss the options of treatment for her.
You have 10 minutes in which you should:
obtain relevant history
address patient concern
outline management plan
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Introduction
expectation and concern
I will need to ask you a couples of questions at any point you find any thing not clear don’t hesitate to ask me well organised history (start with open question)
Current history:
• Can you tell me more about your complaint ………. When she noted this lump Any vaginal discharge
• Any urine leakage did you experience the need to pass urine more frequently ….. have
• difficulty in passing urine………….. or a sensation that your bladder is not emptying properly…………..
• have frequent urinary tract infections (cystitis).
• Any treatment before, Any bowel symptoms .
• Any difficult in sexual intercourse, Use first open questions
• Gynaecology history :Ask about her period regularity …..Last menstrual periods…………..
• Obstetric history Have ever she is pregnant before Weight of the babies Mode of deliveries future fertility
• How many children mode of delivary any complications during delivary and her children situation. (first forceps second
• Medical history any comorbidities chronic cough chronic constipation
• Surgical history any surgery
• Drug history HRT cervical smear
• Social history Smoking (how many years-routine cigarettes) alcohol recreation drugs
• Occupation What do you do for living? lifting heavy things………. Partner support
• Family history of any specific concern
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• The organs within a woman’s pelvis (uterus, bladder and rectum) are normally held in place by ligaments and muscles known as the pelvic
• floor. If these support structures are weakened by overstretching, the pelvic organs can bulge (prolapse) from their natural position
• Being pregnant and giving birth are the most common causes of weakening of the pelvic floor, particularly if your baby was large, you had
• an assisted birth (forceps/ventouse) or your labour was prolonged.
• Being overweight can weaken the pelvic floor. (even as you mention that your mother more obese but she don’t have this problem because
multiple
• factors can cause this weakness.Posterior wall prolapse (rectocele) – when the rectum bulges into the back wall of the vagina.
• With increase age plus if you have chronic cough or constipation .
• stop smoking will benefit your health in all sorts of ways, such as lessening the risk of a wound infection or chest problems after your
• Anaesthetic. will bring immediate benefits to your health.and decrease your weight also will help your bulge to Decrease.
• Pelvic floor exercises may help to strengthen your pelvic floor muscles. You may be referred for a course of treatment to a physiotherapist
• who specialises in prolapse. 16 w
• Vaginal hormone treatment (estrogen) – if you have a mild prolapse and you have gone through the
• menopause; your doctor may recommend vaginal tablets or cream.
• Pessaries are more likely to help a uterine prolapse or an anterior wall prolapse, and are less likely to help a posterior wall prolapse.
• The pessary is a plastic or silicone device that fits into the vagina to help support the pelvic organs and hold up the uterus.
• The aim of surgery is to relieve your symptoms while making sure your bladder and bowels work normally after the operation.
• If you are sexually active, every effort will be made to ensure that sex is comfortable afterwards.
• There are risks with any operation. These risks are higher if you are overweight or have medical problems.
• If you plan to have children, you may choose to delay surgery until your family is complete.
• If you do undergo surgery, you may be advised to have a caesarean section if you become pregnant.

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A pelvic floor repair if you have prolapse of the anterior or posterior walls of the vagina (cystocele or rectocele);
this is where the walls of your vagina are tightened up to support the pelvic organs.
This is usually done through your vagina so you do not need a cut in your abdomen.
In recent years a number of new operations have been developed where mesh (supporting material) is sewn into the vaginal walls.
The risks and benefits of mesh are unclear and it is currently recommended that operations using
mesh are only performed as part of an audit.
• A vaginal hysterectomy (removal of the uterus) is sometimes performed for uterine prolapse.
it might recommend that this be performed at the same time as a pelvic floor repair but as in your condition no prolapse in your
womb.
Sometimes when you are relaxed under the anaesthetic, other areas of prolapse
can become obvious.
You need to sign consent to operate on those areas of prolapse as well.
This should be fully discussed with you before your operation.
Risk of bleeding infection plus anaesthesia complications.
PIL
support group

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 TASK 6
Simulated patient task with lay man examiner
Candidate instructions:
This is simulated patient task will assess the following domains:
Information gathering
Communication with patient
Patient safety
Applied clinical knowledge

You are an ST5 about to see Linda marvel a 43 –year-old lady p3

Complaining of leak of urine with cough
She come to discuss the options of treatment for her.

You have 10 minutes in which you should:

obtain relevant history
address patient concern
outline management plan
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 a) INCONTIENCE history • gynaecology history
continuous or interrupted she felt urge to pass urine if she is wetting herself before • LMP menopausal or no
reach bathroom if she is strain during passing urine or
felt incomplete evacuation of her bladder if she leak with cough or strain . • obstetric history
2) she have similar problem before …………….is this affect her life .
• mode of the delivery CS VD instrument delivary which type
3) pain during her water work how many time she pass urine on the day time or at ventouse forceps fetal weight spinal or epidural anaesthesia
night time (in overactive)…….fever ……..
• Medical history
bladder patient void more than 8 times per day and more than one at night )
4) there is any colour chance in urine like presence of blood • (neurological disease –bronchial asthma-DM-chronic cough-chronic
constipation)
5) she is sexual active or no ……..any leak with sexual intercourse.
• surgical history
b)Precipitating factors
has any disease chronic cough ………. Constipation (and bowel incontinence ……… )
• drug history (diuretic)

6) any bulge from down below as kink of the urethra may occur due to prolapse . • drug allergy contraception ; (contraception-HRT)
7) history of any abdominal mass? Fibroid in details …
any abdominal pain …any irregular vaginal bleeding …..bleeding in-between her • cervical smear up-to-date
period ……
• social history smoking alcohol caffeine support at home
8)any vaginal discharge…
• her occupational lifting heavy used before things support at home.
c)Treatment
9)what about pelvic floor exercise it was supervised or no • a family history of incontinence

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Non-surgical management of urinary incontinence

*Life style modification

Consider advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake.

Advise women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight.

Pelvic floor muscle training

supervised pelvic floor muscle training of at least 3 months' duration as first-line

treatment to women with stress or mixed urinary incontinence.

Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day.

Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training.

Continue an exercise programme if pelvic floor muscle training is beneficial.

Electrical stimulation and/or biofeedback should be considered for women who cannot actively

contract pelvic floor muscles to aid motivation and adherence to therapy.

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Colposuspension

Colposuspension involves making a cut in your lower tummy (abdomen), lifting the neck of your bladder, and stitching it
in this lifted position.
If you have a vagina, a colposuspension can help prevent involuntary leaks from stress incontinence.

There are 2 types of colposuspension:

open colposuspension – where surgery is done through a large cut
laparoscopic (keyhole) colposuspension – where surgery is done through 1 or more small cuts using small surgical
instruments
Both types of colposuspension offer effective long-term treatment for stress incontinence, although laparoscopic
colposuspension needs to be done by an experienced laparoscopic surgeon.
Problems that can happen after colposuspension include difficulty emptying the bladder completely when
peeing, urinary tract infections (UTIs) that keep coming back, and discomfort during sex.

Sling surgery
Sling surgery involves making a cut in your lower tummy (abdomen) and vagina so
a sling can be placed around the neck of the bladder to support it and prevent urine leaking.
The sling can be made of:
tissue taken from another part of your body (autologous sling) tissue donated from another person (allograft sling)
tissue taken from an animal (xenograft sling), such as cow or pig tissue
In many cases, an autologous sling is used. It is made from part of the layer of tissue that covers
the abdominal muscles (rectus fascia).
These slings are generally preferred because more is known about their long-term safety and
effectiveness.

The most commonly reported problem associated with the use of slings is difficulty emptying the bladder
completely when peeing.
A small number of people who have the procedure also find they develop urge incontinence afterwards.

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At the moment, it is not possible to have vaginal mesh surgery for urinary incontinence on the NHS unless there's no
alternative and the procedure cannot be delayed, and after detailed discussion between you as it can cause frequent
problems include:
long-lasting pain
permanent nerve damage
incontinence
constipation
sexual problems
mesh exposure through vaginal tissues and occasionally injury to nearby organs, such as the bladder or bowel

Urethral bulking agents

A urethral bulking agent is a substance that's injected into the walls of the urethra in people with stress incontinence
who have a vagina.
This increases the size of the urethral walls and allows the urethra to stay closed with more force.
Several different bulking agents are available, and there's no evidence 1 is more beneficial than another.
This is less invasive than surgical treatments for stress incontinence in people with a vagina, as it does not usually
require any cuts.
The substance is usually injected through a cystoscope (a thin camera) inserted into the urethra.
Urethral bulking agents are generally less effective than other procedures. The effectiveness of a urethral bulking agent
will also reduce with time and you may need the injection to be repeated.
Many people experience a slight burning sensation or bleeding when they pass urine for a short period after a bulking
agent is injected.
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Artificial urinary sphincter
The urinary sphincter is a ring of muscle that prevents urine flowing from the bladder into your urethra.
In some cases, it may be suggested that you have an artificial urinary sphincter fitted to relieve your incontinence.

duloxetine

You prefer pharmacological to surgical treatment or are not suitable for surgical treatment.

the more common side effects of duloxetine can include:

nausea, dry mouth,

sleepiness,fatigue,
constipation,loss of appetite,
Increased sweating,dizziness

PIL
Support group

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 GB

Thank you

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To all my colleagues, at the end of our course
I'm hoping it will be valuable and useful for all of us.
Forgive me if there is any defect
Nothing can be done without hope and confidence.
All of us has to have a full of confidence.
`Always remember,
success is not final, failure is not fatal, it is the courage to continue.
I have full of trust on all of you and I am sure that you're trusting in Allah.

Remember …..
in the exam you should fight until the end

Ghada Badran
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