Gynaecology Summary Note

I saw Mrs. Sarah Jenkins today, a 48-year-old female presenting with a 6-month history of worsening urinary incontinence and pelvic pressure. Her symptoms are consistent with stress urinary incontinence and a possible pelvic organ prolapse. Name: Sarah Jenkins 48 NHS: 123 456 7890 Hospital number: SJEN001 Chief Complaint: Worsening urinary incontinence and pelvic pressure. Complaint List: - Urinary incontinence - Pelvic pressure History of Present Illness: Mrs. Jenkins presented with a 6-month history of urinary leakage, primarily with coughing, sneezing, and exercise. This has progressively worsened over the last three months, now occurring with moderate physical activity. She also reports a sensation of heaviness and pressure in her pelvis, which is worse by the end of the day and after standing for prolonged periods. She denies any dysuria, haematuria, or urgency. She has not sought medical attention for these symptoms previously but has started using pads daily. Bladder Symptoms: She reports daily urinary leakage with physical exertion, coughing, and sneezing. She voids approximately 6-7 times during the day and once at night. She denies urgency or pain on urination. She occasionally experiences incomplete emptying. Bladder Symptoms: She reports a normal bowel habit, with bowel movements every 1-2 days, soft and well-formed. No straining or sensation of incomplete evacuation. Menstrual History: Regular cycles, 28-day intervals, lasting 5 days, moderate flow. Last menstrual period was 10/10/2024. Menarche at age 13. She is perimenopausal, experiencing occasional hot flushes. No current HRT. Obstetric History: G2P2. Two vaginal deliveries, both full-term, uncomplicated. First child born 20 years ago (3.5kg), second child born 18 years ago (3.8kg). Gynaecological History: No previous gynaecological conditions or surgeries. Contraceptive history: combined oral contraceptive pill for 15 years, then condoms. Sexually active, no dyspareunia. Investigations: Not stated. Past Medical History: Hypertension, well-controlled with medication. No other significant medical conditions. Family History: Mother had a hysterectomy for fibroids at age 55. Maternal aunt had breast cancer at age 60. Past Surgical History: Appendicectomy at age 15. No previous gynaecological surgeries. Medications: Lisinopril 10mg once daily. Allergies: No known allergies. Physical Examination: General appearance: Well-nourished, comfortable. Vital signs: BP 130/80 mmHg, HR 72 bpm. Abdominal examination: Soft, non-tender, no organomegaly. Pelvic examination: External genitalia normal. Speculum examination revealed a stage 2 cystocele with uterine descent to the introitus. No rectocele. Perineum intact. Bimanual examination confirmed uterine descent, mobile uterus, no adnexal masses. Cough stress test positive for urine leakage. Assessment: - Stress Urinary Incontinence (SUI) - Pelvic Organ Prolapse (POP), specifically Stage 2 Cystocele and uterine descent. Plan: Investigations: - Urodynamic studies to confirm SUI and rule out occult stress incontinence. - Renal and bladder ultrasound to assess for hydronephrosis and post-void residual volume. Management: - Pelvic floor muscle training (PFMT) with a physiotherapist referral. - Discussion of conservative management options including pessary insertion. - Discussion of surgical options (e.g., mid-urethral sling for SUI, hysterectomy with sacrocolpopexy for POP) if conservative measures fail or symptoms worsen. Follow-up: - Review in 6 weeks to discuss urodynamic results, response to PFMT, and further management plan.