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A. Midstream urine sample for microbiology
B. Pelvic floor exercises
C. Multichannel cystometry
D. Weight loss
I. Pre-operative counselling in a clinic setting
J. Case discussion in multidisciplinary setting
K. Joint management with urology
L. Botulinum toxin
M. Midurethral retropubic tape
N. Midurethral transobturator tape
O. Open colposuspension
P. Laparoscopic colposuspension
Choose the most appropriate management options for urinary difficulties experienced by women. Each option may be used once, more than once or not at all.
1. A 40-year old presents with leaking urine. Her symptoms mainly occur while coughing, sneezing and gardening. There is also some degree of urgency. There is no incontinence demonstrated on examination. Urodynamics suggest evidence of urodynamic stress incontinence
2. A 76-year old with a BMI of 40 presents with symptoms of incontinence which is affecting her daily life. She is on treatment for heart failure, unstable angina and COPD. Pelvic examination reveals a small cystocele and minimal uterine descent with leakage on coughing. She has already been referred for physiotherapy which has made little difference to her symptoms.
3. A 45-year-old lady presents with symptoms of leaking urine on walking, light running and every time she laughs or sneezes. She does not have any voiding problems. There are no other medical co-morbidities. Bladder diary shows a daily intake of around 1.5 litres. Examination is unremarkable. She has already tried supervised pelvic floor exercises.
A. Paravaginal repair
B. Posterior vaginal wall repair
C. Uterosacral ligament suspension
D. Sacrospinous vault fixation
E. Pelvic floor exercises
G. Abdominal sacrocolpopexy
H. Posterior vaginal wall repair with mesh
I. Traditional anterior repair
J. Shelf pessary
K. Ring pessary
For each of the following case scenarios select the most appropriate treatment from the list of options given above. Each option may be used once, more than once or not at all.
4. A 49-year-old woman presents with ‘something coming down’ for the past 8 months. She has previously had a vaginal hysterectomy for heavy menstrual bleeding. She is sexually active and denies any bladder or bowel symptoms. On examination she has stage 3 apical prolapse and stage 1 anterior prolapse.
5. A 66-year-old woman presents with ‘something coming down’ and difficulty emptying her bowels. She has had a vaginal hysterectomy and posterior repair 2 years ago and was well for the first 8 months post-operation. She does not report any urinary symptoms. She is not sexually active. Examination reveals a stage 2 posterior prolapse, stage 1 apical descent and a well-supported anterior wall.
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