a.I will counsel her in a sympathetic & sensitive way as this is an awkward and difficult situation for the patient to accept the same clinical presentation for which she had been treated six weeks back preferably I will counsel her along with her partner and midwife. I will tell her that the leakage could be of failed surgical procedure, or it could be due to failed detection of exact symptoms of detrusor instability +GSI that there could be mixed incontinence before surgery, then I will explain the symptoms can also be affect of complication of operation like fistula formation and also there is a chance of detrusor instability even after surgery of GSI (as a complication). I will also tell her about urinary tract infection which is a part of complication of surgery.
b. The first thing to reach the diagnosis is ask about the detailed history, she should be asked the present symptom, whether she has got the problem of urge incontinence, urgency, leaking on coughing, sneezing , increased frequency of urine, nocturnal enuresis she will be enquired for chronic cough and constipation .Then her examination will be done , her abdomen will be examined to see for any mass, vaginal examination to see urinary incontinence, Boney?s test will be done to document stress incontinence ,then her pelvic examination is done to feel the site of fistula if present ,mid stream urine to exclude urinary tract infection, ,her blood sugar test will be required to exclude diabetes mellitus ( DI ), there will be a need of urodynamic assessment in case mixed pattern to exclude detrusor instability and GSI. She will be given the frequency urine chart to have a record of fluid intake and output (3 days). Dye test will be needed if there is clue of fistula, to know the exact site within ureter or bladder, and then need of intravenous urography to locate exact site of bladder fistula. Cystoscopy will be needed in case of bladder fistula. Ultrasound is needed to see for residual urinary volume & if any other pathology.
c.The options available for treating her symptoms are first the patient should be told about the conservative measures like improvement of health, chronic cough and constipation is treated. The patient is advised for restricted fluid diet, avoidance of tea, coffee, alcohol which increased urinary frequency. The treatment will depend on the cause detected, in case of urgency, urge incontinence (DI), the patient will be advised antimuscaranic drugs. Most common oxybutine but side effects of any drug will be told to the patient. Sarfenacin is next drug with less side effects can also be given.Tolteridone has got efficacy but side effects of blurring of vision & dry mouth .The patient will be offered Oxybutin patch or intravesical oxybutin. Education of bladder drill will be given. If there is persistent stress incontinence symptom, then the surgery will be repeated but only in the presence of urologist & the patienbt will be advised for complete assessment by urologist. The options are TvT in which sling is pass transvaginally, TOT, same as TVT but more chance of bladder perforation. The other procedure used in case of failed surgery is para urethral injection & urinary diversion(only in specialist clinic).If fistula is suspected repair is advised according to urologist, time and technique is decided by urologist and bladder has to be catherised for 6-12weeks depending on the surgery. The bladder fistula can be repaired abdominally and vaginally. The urinary tract infection will be treated with antibiotics according to culture report.
Incident form will be filled.
