You evaluate a 39-year-old G2P2 on postoperative day 2 following a difficult abdominal hysterectomy for endometriosis. Her surgery was complicated by hemorrhage from the left uterine artery pedicle that required multiple sutures to control bleeding. Her estimated blood loss was 500 mL. Her only other medical problem is obesity, and her prior surgeries are two cesarean deliveries. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are height 5 ft 2 in, weight 250 lb, temperature 38.2°C (100.8°F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 g/dl to 9.8 g/dl, her white blood cell count is 9.5 L, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL.
Which of the following aspects of the patient’s history is the least likely to have contributed to this postoperative complication?
Postoperative ureteral injury is a potential complication following gynecologic surgery. Risk factors for ureteral injury include endometriosis, surgery for malignant conditions, prior pelvic radiation, obesity, prior pelvic surgery, and conditions that impair visualization or tissue planes (such as hemorrhage). Her age is not a risk factor for ureteral injury.
A 59-year-old G4P4 presents to your office with a chief complaint of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where she finds her activities of daily living compromised secondary to fear of embarrassment. Her review of symptoms is negative for urgency, frequency, hematuria, or problems with her bowel movements. Her past medical history is significant for type 2 diabetes, which is well controlled on oral Metformin. She does not take any other medications. Her prior surgeries include a tonsillectomy and appendectomy. Her obstetric history is significant for four vaginal deliveries, weighing between 8 lb and 9 lb. Her last delivery was forceps assisted, and was complicated by a thirddegree laceration. She has been menopausal for 4 years, and has never taken hormone replacement therapy. Her height is 5 ft 6 in, and she weighs 190 lb. Her blood pressure is 130/80 mm Hg.
Based on the patient’s history, which of the following is the most likely diagnosis?
This patient’s history is most consistent with a diagnosis of SUI. Stress incontinence is a condition of immediate involuntary loss of urine when intravesical pressure exceeds the maximum urethral pressure in the absence of detrusor activity. SUI is typically caused by urethral hypermobility, intrinsic sphincter deficiency, or a combination of both. Patients with this condition often complain of urine loss with anything that increases intra-abdominal pressure, such as vigorous physical activity, coughing, laughing, or sneezing. Overflow incontinence typically presents with continuous loss of a small amount of urine, often with associated symptoms of fullness and pressure. Overflow incontinence is usually caused by obstruction or loss of neurologic control. Women with detrusor instability/overactivity have a loss of bladder inhibition, and report symptoms of urgency, frequency, and nocturia. Vesicovaginal fistulas usually occur as a complication of benign gynecologic procedures. Women with this complication usually present with a painless and continuous loss of urine from the vagina. Sometimes the uncontrolled loss of urine is not continuous, but related to a change in position or posture. Women with UTIs usually present with symptoms of frequency, urgency, nocturia, dysuria, and hematuria. Initial treatment for uncomplicated SUI involves lifestyle modification and Kegel exercise. Behavioral modification may include weight loss, scheduled voiding, caffeine reduction and fluid management, smoking cessation, and relief of constipation. Kegel exercises may be taught to strengthen the voluntary urethral sphincter and levator ani muscles. This conservative approach to treatment should be attempted for several weeks before moving on to other forms of treatment such as an incontinence pessary or surgical treatment with a mid-urethral sling. Urodynamic studies do not have a role in the early management of uncomplicated SUI. Pharmacologic therapy, such as anticholinergic medications, is more often used to treat urge incontinence, not stress incontinence.
Which of the following is the best next step in the initial management of this patient?
A 46-year-old woman presents to your office with a chief complaint of “something bulging” from her vagina. She first noticed it 1 year ago, and it has been getting progressively worse. She has also started to notice that she leaks urine when she laughs or sneezes. She has regular periods every 26 days, and her husband had a vasectomy for contraception. After appropriate evaluation and examination, you diagnose a grade 2 anterior vaginal wall defect (cystocele). She has no uterine prolapse or posterior vaginal wall defect (rectocele).
Which of the following is the best treatment plan to offer this patient?
Surgical therapy for SUI and cystocele may be accomplished with anterior colporrhaphy and mid-urethral sling. Placement of a pessary is an option to relieve a cystocele, but is not ideal in this patient, who is sexually active, and feels her quality of life is being impacted. Antibiotics such as Bactrim would be used to treat a UTI, but would not treat a cystocele or SUI. A Le Fort colpocleisis is performed in patients with POP who are poor surgical candidates and not sexually active. The procedure involves obliterating the vaginal canal to provide support to the pelvic structures. Anticholinergic drugs such as Ditropan (oxybutynin chloride) are used to relax the bladder in the treatment of detrusor overactivity. The use of vaginal estrogen cream may relieve vaginal atrophy and improve patient comfort in postmenopausal patients, but it will not correct the cystocele or treat incontinence.
An obese 46-year-old G6P1051 with type 1 diabetes since the age of 12 years presents to your office with a chief complaint of urinary incontinence. She has been menopausal since the age of 44 years. Her diabetes has been poorly controlled for many years. She often cannot tell when her bladder is full, and she will urinate on herself without warning.
Which of the following factors in this patient’s history has likely contributed the most to the development of her urinary incontinence?
Poorly controlled diabetes can result in neuropathies to various organs, including the bladder. This can result in loss of bladder sensation and subsequent overflow urinary incontinence. Diabetes does not cause pelvic relaxation. Natural aging of the tissue, intrinsic weaknesses caused by genetics, birth trauma, hypoestrogenism, and chronic elevation of intra-abdominal pressure because of obesity, cough, or heavy lifting are all factors that contribute to pelvic relaxation.
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