Referral to a Gynaecologist or Urologist.

Your GP may refer you to a physiotherapist as a first line of action or may wish you to see a gynaecologist or urologist. The gynaecologist/urologist will help by running a series of tests called urodynamic tests in order to obtain a definitive diagnosis after which a decision can be made regarding the best course of treatment. There are various tests that may be used and each is carried out as an out-patient procedure. The tests take half an hour to one hour each and your gynaecologist/urologist will decide which test is right for you.It may be that you require physiotherapy, medication, surgery, or a combination of all of these.

Tests Ordered by your Gynaecologist or Urologist.

All tests are carried out as an out-patient procedure:

Urodynamic Tests

These study the activity and the pressures in and around the bladder as it fills and empties. It is necessary for the bladder to be filled with saline, via a catheter and you can expect the test to take between 30-90 minutes depending on which tests your gynaecologist/urologist has ordered:

Pad Testing

With the bladder comfortably full, a standard regimen of simple exercises is performed with a pre-weighed sanitary pad in place. At the end of the exercises the pad is weighed again and the amount of fluid leaked is calculated. Severity can be measured as mild, moderate or severe.

With the bladder comfortably full you will be asked to pass urine into a special toilet that can measure the volume and the flow rate of your normal urination. If the flow rate is slow this may indicate a problem with the urethra or that the bladder can not contract properly.

This is the amount of urine that is remaining in the bladder after urinating, Normally the bladder is empty after voiding. This is measured either by catheterisation or by using an ultrasound machine.

This is the ‘Gold Standard’ test for diagnosing bladder problems. It shows how the bladder responds to being filled with fluid (so called ‘storage phase’) whether you leak urine during filling of your bladder or on provocation and shows how the bladder empties (so called ‘voiding phase’). The test can be performed with X-ray screening (videocystometry) or without. The test involves two tiny catheters being put into the bladder and a further tiny catheter put into the rectum. The bladder is filled with sterile fluid until you have a very strong urge to void. A serious of easy exercises are performed to try to demonstrate urinary incontinence when the bladder is full. Recordings are also made while you empty your bladder.

Throughout the test the machine is gathering a whole wealth of information about your bladder, particularly about the pressure within it, the volume and how it behaves when filled.

After the test a definitive diagnosis can be made.

It may be necessary to measure the pressure inside the bladder and urethra. A tiny catheter is placed within the bladder and slowly withdrawn whilst pressure reading are being taken by the machine.

This gives information about how well the nerves and muscles around the urethra are performing. A very fine needle is passed into the skin around the vagina. This is not painful as the needle is so fine. The needle is attached to an EMG machine and as the needles detect electrical charges from the nerve supplying the muscle a trace can be seen on the screen and recorded. At Pinner Road Physiotherapy EMG is available using a vaginal electrode and is used as a form of biofeedback.

Imaging Techniques.

These give an image of the amount of tearing or wasting that has occurred in the pelvic floor muscles. This can take the form of an ultrasound scan of about 10 minutes, whereby a probe is placed in the vagina and an image will appear on the ultrasound screen which can be recorded. Alternatively an MRI (Magnetic Resonance Imaging) scan will give an excellent view. The scanner is within a tube which takes pictures using magnetic energy. It takes about 30 minutes.

Surgery

There are various types of surgery used to correct stress incontinence.

Colposuspension:

This is the current ‘Gold standard’ operation and the most commonly used. It involves a major operation with an abdominal incision just above the pubic hair. The surgeon places sutures either side of the bladder neck and elevates the bladder neck by tying these sutures to the inside of the bony pelvis. The 5 year success rate for this type of operation is 85-95%. A hospital stay of 5 to 10 days is normal.

Anterior Repair:

This is a "nip and tuck" procedure and is used for cystocele prolapse and / or incontinence. Repair of the prolapse involves removing a piece of vaginal skin, then stitching the bladder and urethra back into the vagina. The operation is performed through the vagina and no scars are visible afterwards.

Needle Suspension Procedures:

These are less commonly used but in principal are similar to Colposuspension. Rather than using the bikini line scar two small incisions are made in the abdomen and another in the vagina.

A Sling Procedure:

This may be performed if other treatments have not been successful. A small incision is made in the vagina and a strip of material is threaded through underneath the urethra.

The material is then picked through another small incision in the abdomen and tied to a ligament inside the pelvis or to the lining of the abdominal wall.

The Manchester Repair:

This may be performed to correct prolapse of the uterus. This corrects the position of the uterus by shortening the cervix.

TVT Procedure:

TVT is the newest urinary continence procedure having been introduced in the UK in 1997. It continues to gain in popularity due to its encouraging results, minimal access and rapid recovery times. It must be borne in mind however that follow up results are not yet available for longer than a seven year period. It may be performed with a local or general anaesthetic as a day case procedure. A Prolene mesh tape is inserted under the mid-urethra via the vagina and passed through the pelvic soft tissue to the abdominal skin involving two small incisions close to the bikini line. The tape is gently taughtend so that it will provide support when the urethra is under strain during provocative activities such as coughing, sneezing or physical exercise. The tape ends are cut and come to lie just under the surface of the skin and each skin incision closed. The mesh remains in place permanently with the body tissues growing into it. Normal levels of physical activity can resume within a matter of weeks following the procedure. The procedure has been available in the UK since 1997 and is available in most NHS Trusts.

Collagen Injections.

Injectable agents, such as collagen, (as used in cosmetic surgery) may be injected around the bladder neck to help keep it in a more closed position. Other substances that may be used include the patients own fat tissue and special types of plastic. The procedure is performed under a local spinal or general anaesthetic and takes about 20 minutes. Although short term results are good the procedure often needs repeating, and therefore this procedure is currently used for those people who are unable to undergo major surgery.

If you are experiencing bladder / pelvic floor problems as discussed in these pages visit:

Your GP or
Your local Chartered Physiotherapist specialising in women's health or
Your local continence advisor

To start an exercise routine click here

To book an appointment at Pinner Road Physiotherapy click here

To find a Chartered Physiotherapist specialising in women's health click here

For other links click here

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