The Mesh Controversy Warning.

Important: Since 2018/2019, the use of Vaginal Mesh (TVT) has been paused/restricted in many countries (UK/NZ/USA) due to complications (Erosion/Pain). Current gold standard guidelines prioritise NON-MESH techniques or very careful consenting.

Conservative (The Big Three)

1. Lifestyle: Weight loss (crucial), Stop smoking (cough), Treat constipation.
   • The Weight Effect: 5-10% weight loss can reduce incontinence episodes by 50%. (Less intra-abdominal pressure).
   • Fluids: "Normal" is 1.5-2L. Many patients drink too much ("flush kidneys") or too little (concentrated urine irritates bladder).
   • Smoking (The Triple Whammy):
     1. Cough: Chronic bronchitis increases intra-abdominal pressure.
     2. Anti-Estrogenic: Smoking lowers estrogen, thinning the urethra.
     3. Collagen: Tobacco damages collagen synthesis, weakening the ligaments.
     • Advice: "Surgery will fail if you keep smoking."
   • Caffeine: Major irritant. Switch to Decaf for 4 weeks as a trial.
   • Bladder Irritants List:
     • Alcohol: Diuretic + Sedative (reduces awareness).
     • Citrus: Oranges/Grapefruit can irritate the trigone.
     • Carbonation: Fizzy drinks (Coke/Sparkling water).
     • Spicy Food: Chilli/Curry.
   • Vaginal Pessaries:
     • Concept: A silicone ring with a "knob" (incontinence dish) that sits in the vagina.
     • Mechanism: The knob pushes up against the urethra, closing it during activity.
     • Role: Great for "Gym-only" leakers. Put it in for the class, take it out after.
   • Vitamin D:
     • Theory: Pelvic floor muscles are skeletal muscles. Vit D deficiency causes myopathy (weakness).
     • Action: Check levels. Supplement if <50nmol/L.

Bowel Management: The "Other" Exit

Rectum full = Bladder squashed.

• The Link: A loaded rectum pushes on the bladder neck, reducing its competence. Straining (Valsalva) weakens the floor further.
• Protocol:
  1. Fibre: Psyllium husk (Fybogel).
  2. Position: Knees higher than hips (squatting stool).
  3. Laxatives: Osmotics (Macrogol) if needed. Avoid stimulants.

2. PFMT (Pelvic Floor Muscle Training):
   • Dose: 8 contractions x 3 times a day for 3 months.
   • Supervision: Must be supervised by a specialist physio (blind Kegels often fail).
   • Success: Cures 50-60%.
   • The "Knack": Contracting BEFORE a cough. Reduces leak by 98% in some studies.
   • Technique: "Imagine stopping wind". "Lift and Squeeze".
   • Common Mistakes: Squeezing glutes/thighs. Holding breath (Valsalva - makes it worse!).

Clinical Skills: Examining the Floor

You can't treat what you can't feel.

• Digital Exam: Insert one finger. Ask patient to "Squeeze me like you are stopping wind".
• Grading:
  • Oxford 0: Nothing.
  • Oxford 1: Flicker.
  • Oxford 3: Lift.
  • Oxford 5: Strong grip.
• The "Glove Test": If you can rotate your finger easily while they squeeze, it's not strong enough.

3. Pharmacology (Duloxetine):
   • Mechanism: SNRI. Increases urethral sphincter tone.
   • Side Effects: Nausea is very common. Insomnia, Dry mouth.
   • Dosing: Start 20mg BD. Titrate to 40mg BD.
   • Counselling: "It reduces leaks by 50%, but rarely cures it completely. Stop if nausea is too bad."
   • Role: Second line if surgery contraindicated.

Surgical

Only after PFMT failure.

1. Autologous Fascial Sling (The comeback kid):
   • Taking a strip of the patient's own rectus fascia and making a sling. No mesh. Higher morbidity (abdominal wound) but safe.
2. Colposuspension (Burch):
   • Open/Laparoscopic surgery to stitch the vagina to the pelvic ligaments.
   • Success: Good (85%).
   • Risk: Prolapse of the back wall (Enterocele).
   • The Procedure:
     1. Incision (Pfannenstiel).
     2. Dissect space of Retzius (behind the pubic bone).
     3. Identify the Paravaginal fascia (white stuff).
     4. Place 2-3 sutures on each side.
     5. Anchor them to Coopers Ligament (on the bone).
     6. "Hikung up" the vagina to support the bladder neck.
3. Bulking Agents:
   • Injecting "filler" (Collagen/Silicon) into the urethra to narrow it.
   • The Procedure:
     1. Cystoscopy (camera in bladder).
     2. Needle inserted trans-urethrally under the mucosa.
     3. Inject material at 3, 6, and 9 o'clock positions.
     4. Watch the urethral lumen "close" (Coaptation).
   • Pros: Local anaesthetic, Day case.
   • Cons: Effectiveness wears off (need repeat every 1-2 years).
   • Brands:
     • Bulkamid: Hydrogel (97% Water). Most common.
     • Macroplastique: Silicone. Permanent.
     • Coaptite: Calcium Hydroxylapatite.
4. Mid-Urethral Slings (TVT/TOT):
   • Subject to local regulations. Synthetic mesh tape. Very effective but mesh risks (Erosion).

Surgical Battle: Choosing the Weapon

The Male Patient: A Different Beast

Usually Post-Prostatectomy.

• Cause: Damage to the external sphincter during radical prostatectomy (RP).
• Prevalence: 5-10% of men post-RP have persistent SUI.
• Treatment Ladder:
  1. PFMT: Essential pre-op and post-op.
  2. Male Sling: For mild/moderate leaks. Compresses the urethra against the bulb.
  3. Artificial Urinary Sphincter (AUS): The Gold Standard for severe leaks.
     • Mechanism: An inflatable cuff around the urethra + Pump in the scrotum. Patient squeezes pump to pee.
     • Physio Tip: "Nuts to Guts". Visual cue for men. Lift the scrotum upwards. Dribble Control: Post-void squeeze to clear the last drops.

The Mesh Scandan (Understanding the Pause)

Why is everyone talking about mesh?

• History: Introduced in 1996 (TVT). Became the gold standard for 20 years.
• The Issue: Reports of chronic pain, mesh erosion (cutting into the vagina/urethra), and dyspareunia (painful sex).
• The Inquiry: The Cumberlege Report (First Do No Harm) in the UK highlighted patient suffering.
• Current Status:
  • Paused: In the UK and NZ for routine use.
  • Available: In the US and Europe (with strict counselling).
  • Note: This applies to VAGINAL mesh. Abdominal mesh (for hernia) is different.

Complications

• Recurrence: Surgery lasts 10-15 years.
  • Stats: 10% fail immediately. 30% recur by 10 years.
  • Risk Factors: Obesity, Smoking, High Impact sport.
  • Management: Re-do surgery is harder. Might need an AUS (Artificial Sphincter) or Urinary Diversion (Stoma) in extreme cases.
• Concept: Sling is too tight -> Obstruction.
• Prevalence: 5-10% of surgeries.
• Mechanism: The urethra is kinked shut even when trying to void.
• Management:
  • Acute: Catheter in hospital.
  • Chronic: CISC (Clean Intermittent Self Catheterisation). Patient learns to pass a small tube to empty bladder 4x/day.
  • Surgical: Sling incision (cutting the tape). Warning: Leak usually returns.

Detailed Surgical Risks (Consent Guide)

What to tell the patient.

1. Failure (10-15%): "It might not work."
2. Voiding Difficulty (5-10%): "You might need a catheter temporarily."
3. Bladder Injury (5%): "If I make a hole in the bladder, I stitch it and you have a catheter for a week."
4. Mesh Erosion (<2%): "The tape can wear through. This is rare but serious."
5. Pain/Dyspareunia: "Pain with sex can happen."

Pregnancy and Future Fertility

The Elephant in the Room.

• Advice: Delay surgery until family is complete.
• Why?:
  1. Pregnancy: Relaxin softens the ligaments -> Recurrence.
  2. Delivery: Vaginal delivery can destroy the repair.
• Protocol: If pregnancy occurs post-surgery -> Caesarean Section is usually recommended to protect the sling.

Key Learning Points (The Pearls)

• The "Two-Step" Cough: Ask them to cough once (to fill the urethra), then again (to leak).
• The "Standing" Test: If dry supine, stand them up. 10% only leak standing.
• The "Trampoline Test": Ask them to do star jumps in clinic.
• The "Paper Towel" Test: Put a brown paper towel on the floor. If they leak, you see the drop size.

GymSafe: Modifying the Workout

Advice for active women.

• Avoid: High impact (Running, Box Jumps, Double-unders). Heavy lifting (Crossfit) increases intra-abdominal pressure.
• Swap For: Cycling (Spin), Swimming, Pilates (Core strength protects the floor).
• The "Brace": Teach them to engage the floor before the lift.

Complications (The De Novo Risk)

• New Urgency: "De Novo" OAB occurs in 10% post-op.

Psychological Impact (The Hidden Cost)

• Isolation: Patients stop going out for fear of leaking.
• Depression: High correlation with incontinence severity.
• Sexual Dysfunction: Fear of leaking during intercourse (Coital Incontinence) leads to avoidance of intimacy.
• Management: Acknowledge it. Refer for counselling if needed.

Post-Operative Recovery Plan

The "6 Week Rule".

• The Concept: The sling/stitches need time to scar into place.
• Restrictions:
  • No Lifting >5kg: Milk bottle only.
  • No High Impact: No running/jumping.
  • No Sex: Allow vaginal healing (risk of infection/pain).
• Driving: 2 weeks (check insurance).
• Work: Desk (2 weeks), Manual (6-8 weeks).

The "Voiding Dysfunction" Nightmare (CISC)