Urogynaecology Letter

Urogynaecologist **Issues** 1. Stress urinary incontinence (SUI) significantly impacting quality of life. 2. Anterior vaginal wall prolapse (cystocele), Pelvic Organ Prolapse Quantification (POP-Q) Stage II. 3. Mild urgency and frequency. **Management** Various management options were discussed, including conservative measures such as pelvic floor muscle training, pessary use, and surgical intervention. The potential risks associated with surgical repair, including infection, bleeding, pain, and the possibility of recurrence or de novo symptoms, were thoroughly explained to the patient. The patient expressed understanding of these risks and opted for surgical intervention. The surgical management plan involves a mid-urethral sling for SUI and an anterior vaginal repair for the cystocele. The patient has been placed on the waiting list for surgery, with an estimated waiting time of 3-4 months. Patient education materials regarding pelvic floor exercises and post-operative care were provided, along with a leaflet detailing the specific surgical procedures. The patient was encouraged to review these materials and ask any further questions at her follow-up appointment. Considering her occupation as a retail manager, Mrs. Smith was advised to avoid heavy lifting and prolonged standing for at least 6-8 weeks post-surgery. Modifications to her work duties, such as delegation of physical tasks, were suggested to her for this period. A referral to a specialist pelvic floor physiotherapist has been made to optimise pre-operative muscle strength and provide post-operative rehabilitation. The rationale for this referral is to enhance surgical outcomes and reduce the risk of recurrence. Follow-up will be scheduled for 6 weeks post-operatively to assess recovery and surgical outcomes. No further investigations are deemed necessary at this stage. **Consultation** I reviewed Mrs. Eleanor Smith, a 58-year-old female, DOB: 12/03/1966, residing at 14 Elmwood Drive, Manchester, M14 5RT, in the Urogynaecology clinic. * Primary presenting issue: Stress urinary incontinence and a feeling of a 'lump coming down'. Mrs. Smith reports a 5-year history of involuntary urine leakage with coughing, sneezing, laughing, and lifting. She states, "It's really affecting my social life; I'm constantly worried about accidents." She uses multiple pads daily and avoids activities she enjoys, such as gardening and walking her dog, due to fear of leakage. This has led to significant embarrassment and a reduced quality of life. She also describes a sensation of heaviness and a bulge in her vagina, which she first noticed approximately 2 years ago and has progressively worsened. She states, "It feels like something is falling out." She experiences discomfort towards the end of the day, which is relieved by lying down. Bladder: Reports occasional urgency and frequency, voiding approximately 8-10 times daily, and 1-2 times nightly. Denies dysuria or haematuria. No history of recurrent UTIs. Bowel: Regular bowel habits, opening bowels every 1-2 days, soft stool. Denies constipation or faecal incontinence. Sexual function: Patient is sexually active with her husband. She reports mild dyspareunia, which she attributes to the sensation of the prolapse. Mrs. Smith has a medical history of well-controlled hypertension, managed with Amlodipine 5mg once daily. She has no known drug allergies. Her surgical history includes a previous appendicectomy at age 12. She denies any prior gynaecological surgeries or interventions. When asked about prior surgeries, she stated, "Just my appendix, nothing else down below." * Para 2 Gravida 2, both vaginal deliveries, last delivery 25 years ago. * No significant family history of gynaecological issues. * Non-smoker, occasional alcohol consumption. * Current medication: Amlodipine 5mg OD. Clinical findings and examination results: * General physical examination: Unremarkable. * Abdominal examination: Soft, non-tender, no palpable masses. * Pelvic examination: Vulva and perineum appear normal. Anterior vaginal wall prolapse noted, corresponding to a cystocele. POP-Q assessment: Aa +1, Ba +1, C -7, D -9, Ap -2, Bp -2, Gh 3, Pb 2, TVL 9. Uterus anteverted, mobile, non-tender. Cervix appears healthy. Rectocele noted, POP-Q Stage I. Perineal body intact. Good voluntary anal contraction. BMI: 28.5 kg/m^2