Gynaecology Summary Note

Urogynaecologist's Note I saw Mrs. Eleanor Vance today regarding her primary concerns of bothersome urinary incontinence and pelvic pressure. She presented with a several-month history of these symptoms, significantly impacting her quality of life. Name: Eleanor Vance 58 years old Chief Complaint: Urinary incontinence and pelvic pressure. History of Present Illness: Mrs. Vance reports a 6-month history of worsening stress urinary incontinence (SUI) and urge urinary incontinence (UUI). The SUI occurs with coughing, sneezing, and light exercise, requiring her to wear pads daily, which she changes 3-4 times a day. The UUI is characterised by sudden, strong urges to void, often associated with leakage if she cannot reach a toilet immediately. She experiences approximately 2-3 episodes of UUI per day and 1-2 episodes of nocturia. She also describes a constant sensation of pelvic heaviness and a bulging feeling in her vagina, worse by the end of the day and after prolonged standing. She denies any dysuria, haematuria, or recent urinary tract infections. She has tried pelvic floor exercises independently with minimal improvement. Bladder Symptoms: Mrs. Vance experiences urinary frequency (voiding approximately 8-10 times daily), urgency with occasional urge incontinence, and nocturia 1-2 times per night. She denies dysuria or haematuria. She has not undergone any specific investigations for her bladder symptoms previously. Bowel Symptoms: She reports occasional constipation, typically having a bowel movement every 2-3 days, often requiring straining. She denies rectal bleeding, pain on defaecation, or faecal incontinence. Her diet is generally low in fibre. Menstrual History: Postmenopausal since age 52. Menarche at 13 years old. Cycles were regular, lasting 5 days. Not on hormone replacement therapy. Obstetric History: Gravida 2, Para 2. Two living children, both delivered vaginally. Her first child weighed 8 lbs 5 oz, born in 1990, and her second child weighed 9 lbs 2 oz, born in 1993. Both deliveries were uncomplicated. Gynaecological History: No previous gynaecological conditions or surgeries mentioned. She used combined oral contraceptive pills from age 18 to 35. Sexually active. No history of sexually transmitted infections. Past Medical History: * Hypertension, diagnosed 5 years ago, well-controlled with medication. * Type 2 Diabetes Mellitus, diagnosed 3 years ago, managed with diet and metformin. Family History: * Mother diagnosed with breast cancer at age 65. * Maternal aunt diagnosed with ovarian cancer at age 70. Past Surgical History: No previous surgery. Medications: * Lisinopril 10 mg once daily * Metformin 500 mg twice daily Allergies: No known allergies. Physical Examination: * General appearance: Well-nourished, in no acute distress. * Vital signs: BP 130/80 mmHg, HR 72 bpm, Temp 36.8°C. * Abdominal examination: Soft, non-tender, no organomegaly. * Pelvic examination: External genitalia normal. Speculum examination revealed a Stage II cystocele and rectocele. Uterus anteverted, mobile, non-tender. Adnexa not palpable. Pelvic floor muscle strength 2/5. BMI: 28.5 kg/m² Assessment: Mrs. Vance presents with mixed urinary incontinence (stress and urge components) and symptomatic pelvic organ prolapse (cystocele and rectocele). The prolapse likely contributes to her sensation of pelvic pressure. Her elevated BMI and history of vaginal deliveries are risk factors. Differential diagnoses include urinary tract infection, although she denies dysuria, and neurological causes of bladder dysfunction, which are less likely given her primary symptoms and lack of other neurological signs. Plan: Investigations: * Urine culture and sensitivity to rule out UTI. * Urodynamic study to further characterise her bladder dysfunction and confirm SUI. * Pelvic ultrasound to assess pelvic organs. Management: * Commence a bladder diary for 3 days. * Refer to pelvic floor physiotherapy for intensive pelvic floor muscle training. * Discuss pessary fitting as a conservative management option for prolapse and incontinence. * Review lifestyle modifications, including weight management and fluid intake. Follow-up: * Review in 4-6 weeks with results of investigations and bladder diary to discuss management options, including potential surgical intervention for prolapse and incontinence if conservative measures are insufficient.