Thank you for sharing the details of Mrs. Catherine's case. You provided a thorough assessment and clear explanation of her overactive bladder condition and management options. Ensuring open communication and addressing her concerns is important for her care.

1. Urogynaec Syllabus
Urogynaec possible scenarios:
• Incontinence and prolapse
In pregnancy
Child bearing age
Postmenopausal lady
• Simulated patient task / Structure discussion:
OAB
SUI
MIXED INCONTINENCE
SENSORY URGENCY
( In structure discussion they can ask about how you manage, can provide you with bladder diary /
cystometry/ flow metry and ask you to interpret and treatment of the case)
Structure discussion:
• Vesicovaginal fistula
• Post partum voiding difficulties
• Fecal incontinence
• Simulated patient task
. Bladder pain syndrome
. Diagnosis given first line options tried no improvement . Now cystometry given and asked to discuss the results
and management in any of the incontinence
Teaching
Pop q ,pessary
CoresurgicaL: Consent for all procedure
Steps of vaginal hysterectomy

2. Session 3
UROGYNAECOLOGY
and
PELVIC FLOOR
Templates

3. Urogynaecology Template
⚫• Introduce yourself + rapport
⚫• Confirm aim of consultation
⚫• Setagenda
⚫• Exploreconcerns
⚫• History
⚫Can you tell me more about the problemyou’ve been having?
⚫Sincewhen?
⚫Wetyourself when you don’t intend to?
⚫Rush to the toilet?
⚫Difficulty starting yoururine stream?
⚫Drippling of urine when u stand afterpassing

4. ⚫Use pads?
⚫Affecting yourwork social life?
⚫Fluid intake perday
⚫Problem opening your bowel?
⚫Doyou feel a Lump in thevagina?
⚫Sexual history: areyou with someone? sexuallyactive? Doyou leak during
sex? (if reproductive age: using contraception?).
⚫Menstrual history +- HRT?
⚫Parity + modeof delivery +- future fertility plans

5. ⚫Past medical history: are you following with your GP forany health
problems?
⚫Surgical history: anyoperations in the past?
⚫Drug history: are you on any medications? Allergic toany drugs?
⚫Family history: anything runs in the family?
⚫Social history (smoke? Alcohol?) + whoare you living with? (support)
⚫• Examination (wtht, abdominal, vaginal)
⚫• Investigations (RBG, urinalysis)
⚫• Explain thediagnosis

6. • Discuss treatmentoptions + risks
⚫• First line:
⚫Bladderdiary
⚫Lifestyle
⚫SPFMT with physiotherapist (SUI) / bladder training (OAB)
⚫• Second line:
⚫Anticholinergics (OAB)
⚫Colposuspension, urethral bulking agents, sling (SUI)
⚫• Third line:
⚫Botox (OAB)
⚫• Explore
⚫• Explorewhat she wants
⚫• PIL
⚫• Write back to GP

7. Pelvic Organ Prolapse Template
⚫• Introduction + rapport
⚫• Confirm aimof consultation
⚫• Exploreconcerns
⚫• Setagenda
⚫• History
⚫Can you tell me more …...?
⚫Sincewhen?
⚫Anything makes itworse? Anything makes it better?
⚫Urinary symptoms: doyou wetyourself when you don’t intend to Problems
with yourwaterworks?
⚫Any problemsopening your bowels?
⚫Constipation, cough, heavy lifting?

8. ⚫Menstrual history – HRT
⚫Sexual history: areyou with someone? Sexually active? Is this lump
affecting yoursex?
⚫Parity + MOD + babyweight +- fertility wishes
⚫Past medical history: are you following with your GP forany health
problems?
⚫Surgical history: anyoperations in the past? (hysterectomy)
⚫Drug history: are you on any medication? Allergic toanydrugs?
⚫Family history: is there anything that runs in the family?
⚫Social history: smoke? Drink? Who doyou livewith? (support)

9. ⚫• Examination (wtht, abdominal, vaginal)
⚫• Explain thediagnosis
⚫• Investigations
⚫• Discuss managementoptions with risks
⚫Lifestylechanges
⚫Pessary
⚫Anterior repair posterior repair
⚫Vaginal hysterectomy
⚫• PIL
⚫• Write back to GP

10. Case 1
Candidates instructions:
This is a stimulated patient task assessing:
⚫ Information gathering
⚫ Communication with patients
⚫ Patient safety
⚫ Applied clinical knowledge
⚫ Communication with colleagues
You are st5 covering Gynaec clinic today .you are about to see Mrs. Williamson Smith,55 yr old referred by her
GP with urinary incontinence while coughing and exercising. She had pelvic floor muscle training which did not
improve her symptoms .filling and voiding cystometry was done and attached is her results. She was sent by her
GP to see your consultant who is on leave today.
You have 10 minutes to
⚫ Take focused history
⚫ Explain results and further management
⚫ Address her concerns

12. Stress urinary incontinence:
⚫ Introduction
⚫ Apologize on behalf of the consultant
⚫ Confirm aim of diagnosis
⚫ I have a letter from your GP stating that you wet yourself when you cough and for that you were advised PFMT
which you did,but it didn't improve your symptoms..is that correct?? .A special bladder test was done and I have
your results with me .
⚫ Set agenda
⚫ Check her concerns
Targeted history:
⚫ History of presenting complaint
⚫ Can you tell me more about your problem

13. ⚫ Is this affecting your life in any way
⚫ Was PFMT supervised? How long you are doing?
⚫ Any lump in the vagina
⚫ Any problem with bowel works
⚫ Menstrual history ..post menopausal?..HRT( vaginal estrogen)
⚫ Past obstetric history
⚫ Medical history
⚫ Surgical history
⚫ Drug history ( allergy)
⚫ Social history- support at home,whom she lives with
⚫ Smoking/ Alcohol/recreational drugs
⚫ Explain the results and diagnosis
⚫ Check knowledge ( do you know what the test was and y it was done for you)
⚫ It's a special bladder test that looks at your bladder how it works and helps us to know the cause for your
waterworks problem and the results help us to decide the best form of treatment for you .
⚫ This is usually done after simple measures like PFMT fails and before surgery.
⚫ You're results confirm that you have a condition called stress urinary incontinence ,have you heard about it??

14. ⚫ It means when sudden extra pressure is put on your bladder like when you cough ,your water pipe cannot stay
closed as it should and some urine leaks out.
⚫ Discuss Management options:
⚫ Regarding the options available for you ,there are 2 surgical options...i will explain each of them... please feel free
to stop in between if you have any questions
⚫ Colposuspension
⚫ Either key hole or small cut in tummy .it involves putting stitches around the neck of the bladder so as to support
it

15. ⚫ 8 out of 10 are satisfied with this surgery
⚫ Explain risks , problem emptying bladder fully, recurrent water infection, bladder may become more irritable and
you may need to rush to toilet ,bulg at back of vagina and doesn't cause any problem and doesn't need any
treatment
⚫ Am I clear ,any questions so far??
⚫ Urethral bulking agents
⚫ It involves injecting a material around the water pipe,it supports and allows it to stay closed and you doesn't leak
⚫ Advantage is no surgery quick recovery….. drawback is long term success is less and might need to repeat as it's
effect wears off with time

16. ⚫ If patient refuses surgery / want to know about medical treatment
⚫ Offer duloxetine ,it helps muscles around your water pipe to contract and keep it closed so you don't leak ...it's
effects strats 3 to 4 weeks after strating the medication and works only as long as you are taking it
⚫ Side effects to be mentioned
⚫ Any questions??
⚫ If patient asks about mesh
⚫ It's right now stopped until extra safety measures are put into place.
⚫ Any questions??
⚫ Before surgery your results will be discussed at a meeting consisting of group of doctors including
urogynaecologist, specialist nurse and physiotherapist ,they will review your results and come up with best
management plan and you will be called in again to discuss the same and you're wishes will be taken into
consideration
⚫ Until surgery you can wear incontinence pads
⚫ Offer further appointment with consultant

17. ⚫PIL
⚫Write back to GP
⚫Thank you

18. Case 2
This is a structure discussion assessing:
⚫ Information gathering
⚫ Communication with colleagues
⚫ Patient safety
⚫ Communication with patients
The examiner is going to discuss with you a case of a 60 yr old woman who underwent vaginal hysterectomy 4
weeks ago. She as now come back with complaints of watery vaginal discharge.
You have 10 minutes during which you are expected to answer the examiners questions

19. 1. What are the possiblecausesof this symptoms?
 Fistula
 UTI
 Pelvic haematoma/ abscess
 Infection
 Overflow incontinence

20. 2. How would you assess this patient to reach a diagnosis?(follow SBAR while answering so you will be systematic
and won't forget points)
 S; this is a case of post hysterectomy incontinence
 B; she had vaginal hysterectomy 4 weeks ago and came with leakage vof fluid per vagina
 A; I would assess her by taking history, examining her and requesting for investigations in order to reach a
diagnosis
History:
 Onset of symptoms
 2.smelly
 3.symptoms like urgency ,frequency, dsyuria (to rule out UTI )
 4.continous leak( vvf/pelvic abscess or she is able to void ( vvf no voiding)
 5.fever, abdominal pain / swelling
 6. Was she prescribed antibiotics did she take them
 7. Gather information from her operative notes for any complications during surgery and to know about her
recovery

21. Examination:
 BP, TEMP, pulse rate
 Abdominal examination for tenderness / palpable bladder, mass
 Will do a gentle Digital vaginal
examination for pelvic collection
 Speculum examination to inspect vault and leak.
 Swab from vault to rule out infection
 Inspect the pad
Investigations:
 FBC
 Urea and creatinine ( for RFT)
 Urine sample for testing
 CT urogram as it is gold standard for diagnosing fistula
 Methylene blue 3 swab test , cystoscopy ( vvf)
 IVU , micturating cystogram to diagnose vvf/ uvf
 Retrograde pyelogram under fluoroscopic guidance

22. 3. Patient was diagnosed with vesicovaginal fistula . discuss the management?
 I like to inform consultant, urologynaecologist
 She needs MDT care urogynaecologist, gynaecologist/ urologist, anaesthetist/ physiotherapist
 Either long term catheterization for 3 months or surgical repair which can be abdominal or vaginal
 Follow up regularly and shared care
 Inform patient , apologize ( duty of candor)
 Fill incident form ,inform risk management team .
 ( Can come as separate question as..what are clinical governance point regarding this case? Then elaborate
and talk on reflective practice ..,arranging a meeting etc)

23. Case 3
Candidates instructions:
This is a simulated patient task assessing
⚫ Information gathering
⚫ Communication with colleagues
⚫ Communication with patient
⚫ Applied clinical knowledge
⚫ Patient safety
You are st5 in Gynaec clinic today , you are about to see Mrs. Catherine Andrew ,48yrs old referred by GP with
urinary incontinence while rushing to toilet. She was seen last week and was asked to complete a bladder diary for
3 days. Her BMI is 30
Attached is her bladder diary
You have 10 minutes during which you are supposed to
Take focused history
Counsel Mrs. Catherine

25. ⚫ OAB
Introduction
Confirm aim of consultation
Set agenda
Check concerns
Information gathering:
 History
 Presenting complaints
 Can you tell me more about your problems( open question)
 Since when
 Rust to toilet
 Difficulty in strating urine stream/ dripping post void
 Urine colour
 Using pads
 Is this affecting your daily life
 Any lump in vagina?
 Problem with bowel opening?
 Menstrual history….finish smear history
 Sexual history...leak during sex
 Obstetric history

26.  Medical
 Surgical
 Drug history... allergy
 Social history... support and her profession
Examination
In presence of chaperone with your consent
Examine tummy feel for any lump
Vaginal examination ( explain how and y….to look at your vagina and neck of womb)
Investigations:
Urine analysis to see for infection
Blood test to measure glucose levels
Explain diagnosis

27. What you have is what we call an overactive bladder...it simply means that your bladder contracts before
you are ready to go to the toilet
Any questions??
Bladders diary that you have filled confirms this and also helps us to explain the management options
which will benefit you
Am I clear ?? Any questions??
Management options:
 We start with lifestyle modifications and conservative management then go to medications if this fails
last option is surgery.
 From your bladder diary I realized you drink lot of coffee and tea so we recommend you to cut down
on them as caffeinated drinks and alcohol can irritate bladder.
 Try to drink 1.5 to 2 ltrs of fluid per day and avoid drinking for 4 hours before going to bed as I can see
you get up in night to wee from your bladder diary
 From your GP letter I can see your weight for height ratio is on higher side so we want to bring it to
normal by lowering your body weight by recommending healthy diet and exercise which can help you
in turn to reduce your urinary symptoms .will that be ok ??? Give pause
 I will give you appointment with dietician.
 We have what we call bladder retraining ...where you train your bladder to hold more urine and will
be able to control your bladder gradually
 Explain bladder retraining

28.  Our specialist nurse will teach you and follow you progress and you will have an appointment after 3 months of
bladder retraining ….any questions??
 After 3 months if your symptoms are not controlled we offer medications called anticholinergic with bladder
retraining….they work by blocking message from your brain to bladder so your bladder don't contract and your
symptoms come down
 Usually it takes 4 weeks to see the action of medications
 Side effects like dry mouth, constipation ,flushed skin can occur
 If you can't tolerate tablets for side effects or tablets don't work ,you will be offered special test called
urodynamic s to know how your bladder is functioning and discuss your case with team of doctors called MDT to
come up with suitable surgical options for you
 like injecting medications to your bladder muscle to paralyze it
 Inserting a small device under your skin that sends electrical signals to your bladder

29.  Inserting a small device under your skin that sends electrical signals to your bladder
 Or a small piece of bowel from your intestine is added to bladder to increase it's capacity to hold urine more
 All the above options will be discussed with you in detail if necessary arises at a later date .any questions? am I
clear so far?

 So Mrs. Catherine I would like to give appointment with dietician and also specialist nurse to strat you on bladder
retraining and offer you some information leaflets
 Write back to your GP
 Thank you
SENSORY URGENCY same management ……..urodynamics will be normal

30. Case 4
Candidates instructions:
This is a simulated patient task assessing:
• Information gathering
• Communication with patients
• Patient safety
• Applied clinical knowledge
You are about to see Mrs. Rossy Smith 33- year-old in 28 weeks of her pregnancy referred by her midwife with
complaints of lump in her vagina for past 2 months with dragging pain and heaviness…..your consultant is away
and you are attending antenatal OPD behalf of her.
You have 10 minutes during which you are supposed
o To take focused history
o Discuss Management plan
o address her concerns

31. Examination findings :
Abdominal
Fundal height 28 weeks
Longitudinal lie with cephalic presentation
Speculum examination
Stage 2 cystocele
No rectocele
No uterine prolapse

32.  Introduction
 Confirm aim of consultation
 Set agenda
 Check concerns
 Information gathering
 History of presenting complaints
 Start with open questions...can you tell me more about your problems??
 Since when?
 Anything makes it better or worse?
 Problem with water works ?opening bowel?
 Cough , heavy lifting weights
 History regarding pregnancy whether first/ planned?...how is she doing so far in this pregnancy?
 Obstetric history

33. Sexual history:
⚫ Whom do you stay with/supportive
⚫ Is this affecting your sexual life
⚫ Any discharge from below or sti in past ( patient safety for pessary)
⚫ Medical history
⚫ Surgical history
⚫ Drug history ...rule out allergy
⚫ Family history ….of prolapse or connective tissue disorders
⚫ Social history ... occupation, smoking, Alcohol., recreational drugs

34. Examination:
⚫ Explain what and y and how you do it
⚫ (In presence of chaperone)
Explain diagnosis:
⚫ We call this Prolapse of organs in your pelvis ( cystocele).
⚫ Normally the organs like bladder,womb and bowel are supported with group of muscles and ligaments in our
pelvis to hold them in natural position ,with repeated deliveries this may get weaker and the organs can bulge
down .in your case what I found on examination is that bladder is bulging through the front wall of your vagina
and hence you have heaviness and bulge
⚫ This may increase as your pregnancy progresses but we do have some options to control the symptoms
⚫ Like special exercises which helps to tone your pelvic muscles and a device called pessary
⚫ Pessary helps to keep the bladder in place works like an artificial support from outside till your delivery
⚫ Any questions ?? Am I clear??

35. ⚫ I like to offer appointment with physiotherapist for supervised pelvic floor exercises and appointment with my
consultant of you want to discuss further about pessary and patient information leaflets
⚫ Write back to your midwife
⚫ Thank you
Home work:
⚫ Pregnancy with PROLAPSE
⚫ Postpartum SUI
⚫ Had incontinence surgery and wants to conceive
⚫ Briefly explain management options for all these cases .