Urogynaecology Letter

Dear Dr. Sarah Jenkins, I am writing to you regarding Ms. Eleanor Vance, whom I reviewed in the Urogynaecology clinic on 1 November 2024. Issues 1. Stress urinary incontinence (SUI) 2. Pelvic organ prolapse (POP), specifically uterine prolapse. Management We discussed various management options for her stress urinary incontinence and pelvic organ prolapse. For SUI, conservative options such as pelvic floor muscle training and lifestyle modifications were explained, alongside surgical options including mid-urethral slings (e.g., TVT, TOT) and Burch colposuspension. The associated risks, such as infection, pain, mesh erosion, and failure rates, were thoroughly reviewed. For POP, we discussed pessary management and surgical repair options, including vaginal hysterectomy with pelvic floor repair. The risks, including bleeding, infection, damage to surrounding organs, and recurrence, were also explained in detail. Ms. Vance has opted for surgical management for both her SUI and POP. A tension-free vaginal tape (TVT) procedure is planned for her SUI, and a vaginal hysterectomy with anterior and posterior colporrhaphy for her POP. She has been placed on the waiting list for surgery, with an anticipated wait time of approximately 4-6 months. Patient education materials from the Royal College of Obstetricians and Gynaecologists regarding stress urinary incontinence and pelvic organ prolapse surgery were provided, along with information on post-operative care and recovery. Ms. Vance is a primary school teacher. We discussed the need for her to avoid heavy lifting and prolonged standing post-surgery, advising a minimum of 6 weeks off work, with a gradual return to full duties thereafter. A fit note will be provided. Referrals were made to the pelvic floor physiotherapy team for pre-operative assessment and to initiate pelvic floor muscle training, as well as to a dietician for advice on managing chronic constipation, which may exacerbate her prolapse. She is scheduled for a follow-up appointment in 3 months' time to review her progress and discuss pre-operative preparations. Pre-operative investigations including urine culture, full blood count, and renal function tests have been requested. Consultation I reviewed Ms. Eleanor Vance, a 58-year-old female (DOB: 15/03/1966), residing at 12 Elm Street, Anytown, in the Urogynaecology clinic. * Primary presenting issue: Stress urinary incontinence and sensation of a vaginal bulge. Ms. Vance reports a 5-year history of involuntary urine leakage with coughing, sneezing, and laughter, which has worsened over the past year. She uses 2-3 pads daily, stating, "I can't even laugh without worrying about leaking." This significantly impacts her social activities and exercise routine. She also describes a persistent sensation of something coming down in her vagina, particularly at the end of the day, which she describes as "a heavy feeling, like everything is falling out." This causes discomfort and affects her ability to walk long distances. Bladder: Reports significant stress urinary incontinence. No symptoms of urgency, frequency, nocturia, or dysuria. Good bladder emptying. Bowel: Reports chronic constipation, requiring laxative use 2-3 times per week. Strains significantly with bowel movements. No faecal incontinence. Sexual function: Ms. Vance is sexually active. She reports some discomfort during intercourse due to the sensation of the vaginal bulge, but no dyspareunia otherwise. Her partner is supportive. Her medical history includes well-controlled hypertension on Ramipril 5mg OD and mild asthma managed with Salbutamol as needed. She had an appendectomy at age 12 and two uncomplicated vaginal deliveries at ages 28 and 30. She reports good recovery from these previous surgeries with no complications. * Relevant medical history: Hypertension, mild asthma. * Surgical history: Appendectomy, two vaginal deliveries. Clinical findings and examination results: * General examination: Unremarkable. * Abdominal examination: Soft, non-tender, no masses. * Pelvic examination: Grade 2 cystocele, Grade 3 uterine prolapse (leading edge 1 cm beyond the hymen), Grade 1 rectocele. Good pelvic floor muscle tone, Oxford Scale 3/5. BMI: 28.5 kg/m² Yours sincerely Dr. Anya Sharma Consultant Urogynaecologist