The Women of Camden and Islington (and some from Barnet too!) Managing incontinence and prolapse

1. The Women of Camden and Islington(and some from Barnet too!)Managing incontinence and prolapse Suzy Elneil

2. Who are they? • Demography • Countries of origin • Religions • Culture • Specific health problems?

3. The New Women of C & I • Somalia/ Bangladesh • Moslem • Entrenched cultural practices • Health issues are many

4. Incidence Main Aetiology is Obstetric Injury Maternal Mortality Rates (in a lifetime) Scandinavia 1:300000 Africa 1:12 NB: No. of women who die annually in West Africa equals all those who died in Korean conflict in 1950s

5. Morbidity • Main focus in the literature is mortality • However, for every death reported 20 women suffer long term problems • Wide range of conditions

6. The Scope of the Problem Mental Health Problems Domestic Violence Chronic Infections Pain Complex Genital Tract Fistulas Postpartum Haemorrhage and its effects Perineal Trauma Uterovaginal prolapse and incontinence

7. Ball Park Statistics • 10-60% of women report urinary incontinence • 10% of women with urinary incontinence also have incontinence of flatus or stool • 50% of women who have children develop prolapse BUT Only 10-20% seek medical help in Western Europe < 2% seek help in the developing world

8. Classification of FGM

9. Age Age at circumcision Race/Culture References At Birth Some Igbo people in Nigeria Basden, 1966; Megafu, 1983 Neonatal Period Parts of Ethiopia Meskal et al., 1990 Infancy Parts of the Middle East WHO, 1998 and Nigeria Diejomaoh &Faal, 1981 Childhood Most African societies El-Saadawi, 1980 e.g. Sudan, Egypt, Somalia Sayed, 1996 Teenagers Some Bantu tribe and Australian Aborigines WHO, 1998 Before or at marriage Masai tribe, Yako tribe of Nigeria Forde, 1941 After birth of 1st child Swahili speaking communities Forde, 1941

10. What are the problems?  Immediate Complications Death Shock and Pain Haemorrhage Infection including septicaemia Adjacent organ damage Acute Urinary Retention Fracture/Dislocation of the femur, humerus or clavicle Long Term Complications Failure of healing Recurrent UTI and Renal/Bladder Calculus formation Urethral obstruction and voiding dysfunction Sexual Dysfunction Fistulae Incontinence and prolapse Pelvic Infections and Abscess formation Menstrual Abnormalities and associated Infertility AIDS, HIV and other blood borne diseases Problems with pregnancy and childbirth Psychological or Psychiatric problems (Dirie and Lindmark, 1991b, 1992; Rushwan, 2000; WHO, 1998)

11. African Women’s Clinic with S Creighton

12. Genital Tract Fistulas A major health problem in developing countries as a consequence of obstructed labour In developed countries GTF are usually iatrogenic or following radiotherapy or foreign body injury

13. What if she is lucky?

14. Underactive Pelvic Floor Dysfunction Urodynamic Stress Incontinence Prolapse Resulting in Bowel/Sexual/Bladder Dysfunction respectively

15. Quality of Life Impact Physical • Fear of losing bladder/ bowel control • Fear of pain • Dealing with chronic infections Social • Embarrassment • Affects lifestyle and avoidance of activities • Impact on all relationships • Increased dependence on caregivers Personal • Mental Health • Domestic Violence

16. Mental Health Issues • Depression • Suicidal risk • Mania

17. Management History • Medical, neurological, genitourinary history • Assess mental status and mobility Examination • General, • Abdominal, pelvic, rectal, lower limbs

18. General Nutrition Anaemia Infection Lifestyle/ Behavioural Modification Fluid management Advise on harmful cultural practices Simple Interventions Physiotherapy Pessaries/ Continence devices Pharmacotherapy Management

19. The ‘Incumbent’ Ladies of C & I

20. Why are we prone to UVP and Incontinence? External factors PREGNANCY & CHILDBIRTH AGEING Hormone effects Non-obstetric pelvic trauma and radical surgery Increased intra-abdominal pressure Drug effects Inherited/ Genetic factors Race Anatomic differences Connective tissue Neurological abnormalities

21. Post partum Clinic at UCLH Started in 2008 MDT Team: Consultant Urogynaecologist Consultant Midwife CNS in Urogynaecology CNA in Urogynaecology CF in Urogynaecology & Functional Gastroenterology Physiotherapist Conditions: Perineal trauma and ano-rectal sphincter tears Urinary or faecal incontinence Voiding dysfunction Acute/chronic urinary retention Sexual dysfunction Counselling Post childbirth Pre-pregnancy Contact urogynaecology@uclh.nhs.uk

22. Urogynaecology Clinic at UCLH MDT Team Consultant Urogynaecologist Consultant Geriatrician CNS Urogynaecology CNA Urogynaecology Physiotherapist Sub-speciality Trainee in Urogynaecology Clinical Fellow in Urogynaecology Conditions Urinary/Faecal Incontinence Utero-vaginal prolapse Obstructive voiding or evacuation Bladder pains syndromes Recurrent UTI Clinics Urogynaecology CNS led Urodynamics Ring Pessary CNA led Recurrent UTI Post-op Clinic Contact urogynaecology@uclh.nhs.uk

23. CYSTOCOELE

24. Absorbable Mesh But Its Porcine!

25. UTERINE PROLAPSE

26. Vaginal Pessaries Serious issues regarding hysterectomy

27. RECTOCOELE Bowel Function and Sexual Function are a concern, and surgery resisted

28. Sacrospinous Fixation

29. Laparoscopic Suspension Procedures • Sacro-colpopexy • Sacro-hysteropexy • Sacro-cervicopexy • Suturo-pexy Use of non-absorbable mesh

30. Complications • Functional • Bowel, Bladder and Sexual • Surgical • Bleeding, Pain, Infection, Recurrence • Mesh • Erosion, Functional, Infection, Pain

31. Uro-neurology at UCLH/NHNN MDT Team Consultant Neurophysiologist Consultant Urogynaecologist Consultant in Functional Gastro-enterologist Consultant Urologist CNS in Uro-neurology CNS in Neuromodulation CSN in Uro-neurology CF in Uro-neurology Conditions All neurological conditions affecting the bladder, bowel and pelvic floor Chronic voiding dysfunction and urinary retention in men and women Idiopathic OAB with intractable responses Services Botulinum toxin in the bladder Sacral neuromodulation Medical therapy in MS, PD, MSA Contact sheila.reynolds@uclh.nhs.uk

32. Mental Health Issues • Depression • Social adaptation • Coping ability • Loss of confidence Anxiety regarding childcare, home help, religious duty, self-care

33. Multi-Disciplinary Holistic Approach Essential to medical and operative success Multiple medical therapies and surgical techniques available Incontinence and Prolapse presentations can often be compound/complex Understand religious, cultural and social practice

34. Conclusion And this, he said, is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also; for the part can never be well unless the whole is well Socrates