(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).
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