Australian Doctor 13th Sept Issue | Page 32

13 SEPTEMBER 2024 ausdoc . com . au pressure . Short-term success rates of 80-90 % are reported , with longterm success rates of 50-70 %.

39 , 40

This procedure requires follow-up for six months or more , though complications may present later . Potential complications include chronic pain , urinary retention , perforation of bladder or urethra , de novo urgency ( 9.8 %) and

39 , 40 mesh exposure ( 2-3 %).

Refer patients with complications from mesh to a team or surgeon credentialed to perform this work . Because of both the US FDA ban on POP mesh and public concerns about all transvaginal mesh , the use of transvaginal tape ( TVT ) has declined dramatically . This includes retropubic TVT , which has a low risk of mesh erosion . As a result , alternative treatment options , such as bulking agents , are becoming an increasingly popular

41 , 42 treatment for SUI .

Pubovaginal fascial sling This requires a combined abdominal-vaginal approach where the patient ’ s rectus fascia is harvested and placed under the proximal urethra , with the ends secured via permanent sutures . This avoids the long-term risk of foreign body

ICIQ-UI Short Form

Initial number CONFIDENTIAL DAY MONTH YEAR Today ’ s date

Many people leak urine some of the time . We are trying to find out how many people leak urine , and how much this bothers them . We would be grateful if you could answer the following questions , thinking about how you have been , on average , over the PAST FOUR WEEKS .

1 Please write in your date of birth :

Copyright © “ ICIQ Group ” contracture or extrusion . Shortterm success rates of 80-90 % and long-term success rates of 50-70 % 43 are reported , which are better than those reported for Burch colposuspension , described below ( 66 % vs 49 %). 43

However , higher rates of complications are also reported , compared with Burch colposuspension , such as urinary tract infection ( UTI ) at a rate of 48 % vs 32 % and voiding dysfunction ( 14 % vs 2 %). 43

A pubovaginal fascial sling procedure has similar morbidity to a retropubic mesh sling , however the former has additional short-term risks related to graft harvest . 44

Burch colposuspension In this abdominal procedure , performed via an open , robotic or laparoscopic approach , sutures are used to suspend the vagina lateral to the bladder neck to the iliopectineal ligaments on the pelvic side of the pubic bone . Mesh is not required , but this procedure has a higher risk of failure and prolapse in the long term . 45

PROCEDURES FOR OAB Intravesical onabotulinumtoxinA These are injected cystoscopically into the bladder to block

DAY MONTH YEAR 2 Are you ( tick one ): Female Male

3 How often do you leak urine ? ( Tick one box )

all the time

5

4 We would like to know how much urine you think leaks .

How much urine do you usually leak ( whether you wear protection or not )? ( Tick one box ) none

0

5 Overall , how much does leaking urine interfere with your everyday life ? Please ring a number between 0 ( not at all ) and 10 ( a great deal )

ICIQ score : sum scores 3 + 4 + 5

6 When does urine leak ? ( Please tick all that apply to you ) never – urine does not leak leaks before you can get to the toilet leaks when you cough or sneeze leaks when you are asleep leaks when you are physically active / exercising leaks when you have finished urinating and are dressed leaks for no obvious reason leaks all the time

Thank you very much for answering these questions .

Figure 2 . International Consultation on Incontinence Questionnaire .

International Consultation on Incontinence Questionnaire ( ICIQ ) © Bristol Urological Institute acetylcholine release from the neuromuscular junction , resulting in partial paralysis of the detrusor and reduced muscular activity . This also alters sub-urothelial nerve activity and reduces afferent nerve input . The effect lasts for 6-9 months on average .

Table 2 . Basic investigations Investigation

Urine dipstick and midstream urine ( MSU )

Bladder diary

Urinary tract ultrasound ( UT U / S )

Detail

Incontinence without typical dysuria may resolve if treated with the appropriate antibiotics It is important to differentiate UTI from bladder disorder ; concomitant treatment may be required , including longterm methanamine 32 , until chronic infection has resolved

Acute infection is typically associated with dysuria during voiding , frequency and urgency Chronic infection , especially when bladder sensation is impaired ( eg , with diabetes mellitus , chronic analgesia use ) may render the irritative aspects of the infection insensible , manifesting as incontinence , sepsis , confusion and malodour instead of the typical dysuria

If UTI is present on mid-stream urine , initiate the appropriate antibiotics and review the patient one week after completion to determine the impact on incontinence If incontinence is refractory to treatment for the UTI , further evaluation is required , starting with a frequency volume chart Cellular content , including squamous cells , should normalise when the infection resolves

A frequency volume chart completed by the patient to record the voided volumes and time can be useful This does not incur a cost and has no side effects , and guides the clinical direction Typically , patients keep a 24-hour record on two or three occasions ( see figure 3 ) Intake may be recorded as well , though it tends to increase the chart complexity and may jeopardise the outcome

Important points to consider :

• Total urine output should be 1.5-2L with at least one void of greater than 400cc

• Urinary frequency should be less than eight times over 24 hours

• Percentage voided during sleep interval should be less than one-third because of renal concentration

• Under- or over-drinking can affect symptoms

• It is useful for the patient to record whether they have leaked before voiding , as an index of severity and response to treatment

• Low total intake and output may be linked to avoidance of fluids to prevent incontinence

• Low total output with small voided volumes may be because the patient is trying to prevent incontinence or discomfort

• Pain , discomfort or pressure on deferral of urination indicates a sensory or epithelial disorder

• If there is a high total output with high voided volumes ( great than 3L ) with urgency , urinary frequency and nocturia , patients may have an excessive fluid intake or may be trying to remedy constipation , though high water intake is ineffective for this

• High fluid intake exacerbates LUTD and may not help constipation

Check post-void residual volume ; this is useful when starting anticholinergic medication Other abnormalities , such as hydronephrosis or urolithiasis may be revealed on ultrasound , prompting urological management

Figure 3 . This bladder diary demonstrates leakage associated with higher volumes in a patient with OAB .