CCE-CBD-152

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the possible types of urinary incontinence Karen may be experiencing? How do you differentiate them?

• Prompt: Explore stress vs urge vs mixed incontinence
• Prompt: Discuss history and examination findings relevant to diagnosis
• Prompt: Consider impact of prior hysterectomy

Q2. How would you approach the management of Karen’s urinary incontinence in a rural setting?

• Prompt: Explore conservative, pharmacological, and referral options
• Prompt: Discuss pelvic floor exercises, bladder training, and weight management
• Prompt: Consider local services or telehealth for continence support

Q3. What investigations, if any, would you order before referring Karen?

• Prompt: Rationalise need for urinalysis, bladder diary, post-void residual
• Prompt: Discuss urodynamics if conservative management fails
• Prompt: Address when referral is needed

Q4. How would you address Karen’s concerns about surgery?

• Prompt: Explore non-surgical management success rates
• Prompt: Provide reassurance, explain risks/benefits of surgical interventions
• Prompt: Offer information on minimally invasive options if needed

Q5. What preventive health considerations are relevant in this consultation?

• Prompt: Address weight management, osteoporosis prevention
• Prompt: Discuss exercise, smoking/alcohol (if relevant), pelvic floor maintenance
• Prompt: Ensure vaccinations and cancer screenings up to date

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the possible types of urinary incontinence Karen may be experiencing? How do you differentiate them?

Answer:

Karen is likely experiencing stress urinary incontinence (SUI), although mixed urinary incontinence (MUI) should be considered. The types of incontinence include:

• Stress Urinary Incontinence (SUI): Involuntary leakage on effort or physical exertion (e.g., coughing, sneezing, exercising). It’s typically due to pelvic floor muscle weakness, commonly seen post vaginal deliveries and with obesity.
• Urge Urinary Incontinence (UUI): Involuntary leakage accompanied by urgency, often related to overactive bladder syndrome.
• Mixed Urinary Incontinence (MUI): A combination of both stress and urge symptoms.

Differentiating Features:

• History Taking:
  • Onset, duration, and triggers of leakage.
  • Circumstances: coughing, sneezing (SUI) vs sudden urgency without clear triggers (UUI).
  • Nocturia and frequency support UUI.
  • Amount of leakage and pad usage.
• Risk Factors:
  • Age, menopause, parity, obesity (BMI 31), previous pelvic surgeries (hysterectomy).
• Physical Examination:
  • Pelvic exam: reduced pelvic floor tone suggests SUI.
  • No prolapse rules out contributing factors like cystocele.
  • Neurological examination: normal, reduces likelihood of neurogenic bladder.

Given the absence of urgency symptoms in the history, SUI appears predominant. Her history of multiple vaginal deliveries and obesity further supports this.

Q2: How would you approach the management of Karen’s urinary incontinence in a rural setting?

Answer:

Conservative Management (First-line):

• Pelvic Floor Muscle Training (PFMT): Supervised by a pelvic health physiotherapist if available; otherwise, telehealth consultation. Aim: 3 sets of 8–12 contractions daily for 3 months.
• Weight Reduction: Address BMI 31; encourage gradual weight loss via diet and exercise.
• Bladder Training: Typically more for UUI, but some crossover benefit.

Lifestyle Modifications:

• Limit caffeine, alcohol.
• Encourage fluid balance (avoid excessive restriction).
• Address constipation if present.

Pharmacological:

• Rarely indicated for pure SUI. Duloxetine can be considered if conservative measures fail and surgery is not an option.

Referral Options:

• Rural health services/continence clinics.
• Telehealth urologist or gynaecologist if needed.

Q3: What investigations, if any, would you order before referring Karen?

Answer:

• Bladder Diary (3 days): Tracks frequency, volume, leakage episodes.
• Post-void Residual (PVR): Already completed (40 ml), reassuring.
• Urinalysis/MCS: Completed—normal. Rule out infection.
• Pad Test (optional): Quantifies incontinence severity.
• Urodynamic Studies: Consider if surgery is planned or diagnosis unclear.
• Pelvic Ultrasound (optional): To assess post-hysterectomy anatomy if concerns arise.

Q4: How would you address Karen’s concerns about surgery?

Answer:

• Reassure that surgery is not the first step; conservative measures are highly effective.
• Discuss mid-urethral sling as the common surgical option, its risks (bladder injury, mesh complications), and benefits.
• Explore non-surgical alternatives: PFMT success rates (50–70%).
• Telehealth consultations can help explore options without travel.
• Empower Karen in shared decision-making, respecting her concerns and preferences.

Q5: What preventive health considerations are relevant in this consultation?

Answer:

• Weight Management: Reduces incontinence symptoms and cardiovascular risk.
• Bone Health: Osteopenia noted—consider calcium, vitamin D, weight-bearing exercise.
• Pelvic Floor Maintenance: Encourage ongoing PFMT regardless of symptom improvement.
• Cardiovascular Screening: Continue BP and lipid management.
• Vaccinations: Confirm up to date (influenza, pneumococcal, shingles).
• Cancer Screening: Confirm mammograms; no further cervical screening required post-hysterectomy for benign reasons.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive identification of types of urinary incontinence with clear differentiation.
• Thorough conservative management plan tailored to a rural setting.
• Appropriate investigations based on history and examination.
• Patient-centred discussion addressing concerns about surgery.
• Holistic preventive health management beyond the presenting issue.

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PITFALLS

• Failing to differentiate SUI from UUI/MUI in history-taking.
• Omitting pelvic floor muscle training as first-line management.
• Recommending surgery prematurely without exhausting conservative options.
• Ignoring psychosocial impact on Karen’s quality of life.
• Neglecting preventive health discussions, particularly weight management and bone health.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Australian Continence Foundation
• eTG (Therapeutic Guidelines)
• NICE Guidelines on Urinary Incontinence in Women

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors and behaviours.

6. Professionalism

6.1 Adopts a patient-centred approach in complex and challenging situations.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care effectively.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient expectations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages severe acute and chronic health conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural and remote healthcare needs and resources.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD