Clinical risk assessment encompasses assessment of the risk factors inherent in the patient as well as those of the intervention or proposed management. This article has tried to highlight the salient points which should be kept in mind while managing urogynecological problems with special reference to post-menopausal women.
Genital prolapse often presents in a non-specific manner and the degree of impact it causes can be quite variable. Tailoring the management to the individual is therefore essential. There is increasing consensus that functional outcome and patient QoL (with patient selected goals) are better outcome measures than just a good anatomical correction of prolapse. Initial enthusiasm for mesh-kits for prolapse repair has been tempered with caution following intense publicity around some of the complications and appropriate patient selection and counseling are required. Laparoscopic techniques for prolapse repair are gaining popularity and the use of mesh in this environment seems to have much lower complications.
For the OAB, newer generations of M3 receptor selective anti-muscarinic agents, as well as newer delivery systems (transdermal), have improved the side-effect profile and given the clinician more options, however there are no comparative trials. The new β-3 adrenergic receptor agonist is a promising option for those who cannot tolerate anticholinergics. Botulinum toxin A injection and neuromodulation (percutaneous posterior tibial nerve stimulation and sacral nerve stimulation) are suitable alternatives for those non-responsive to medications, but the availability of these options is variable, especially in the case of neuromodulation where specialist expertise is required.
Urogenital atrophy, which can aggravate other conditions and cause miserable symptoms, is under-reported and under-treated. Non-hormonal moisturizers, vaginal estrogen and systemic HRT are all effective options for as long as they are taken. New selective estrogen receptor modulators have shown encouraging results in treatment of vaginal dryness and dyspareunia in atrophic vulvovaginitis. Painful bladder syndrome remains a conundrum and ongoing research is trying to underline the common cause behind all chronic pain syndromes. Until then, multidisciplinary multi-modality treatment will remain the mainstay of treatment.
Expert Rev of Obstet Gynecol. 2013;8(6):625-637. © 2013 Expert Reviews Ltd.