Trial of Void (Emptying Bladder) Immediately After Incontinence &/or Prolapse Surgery

Following incontinence or pelvic reconstructive surgery it is necessary to ensure that your bladder is emptying effectively. This is assessed during your stay in hospital.

You will be asked to use a pan placed over the toilet every time you empty your bladder so that the nursing staff can measure the amount of urine that you have passed. The nurse will then measure the amount of urine left in your bladder (residual volume) using the bladder scanner. This is a non-invasive, non-painful method of estimating the residual.

This protocol will be repeated until either you have passed urine leaving less than 100mls on two consecutive occasions or alternative instructions are given by Dr Onuma.

General Guide:

1. When voiding, remember to sit comfortably on the toilet with your feet flat on the floor. Lean forwards.

2. Try and relax.

3.If necessary run a tap whilst trying to void.

4. Drink normal (for you) amounts of fluid (usually about 1.5 – 2 litres/day).

5. Avoid going to the toilet ‘just in case.’

6. If at any time you have difficulty passing urine or feel your bladder is uncomfortable, please tell a member of the nursing staff as soon as possible.

7. If you are unable to void or there are large volumes of urine left in your bladder after you have attempted to void, it may be necessary to manually empty the bladder with a catheter. Sometimes a decision will be made (by Dr Onuma) to leave a catheter in the bladder overnight to ‘rest’ the bladder. On removal of the catheter, another ‘trial of void’ will be conducted.

8. Don’t be disappointed if your ‘trial of void’ is initially unsuccessful. It may take a little more time for your bladder to regain its tone and function. The more stressed you become, the more likely that your bladder will delay returning to its normal function.

Surgery Admission Guide

The following is a guide to the information provided to patient's individually at their consent to surgery appointment. The information that applies to any individual patient will always be specified by Dr Onuma, and time allowed for detailed discussion and clarification of any issues that arise.

Please Read Carefully

• If you are having laparoscopic (keyhole) or open surgery, then please remove all of the top 2cm of pubic hair 2-3 days before your operation.
  
  
• Your surgery requires that you remove (trim, shave or wax) all pubic hair around the vagina and labia 2-3 days before your operation.
  
  
• You are required to have some blood taken from the lab (Gribbles/Clinpath/IMVS) in preparation for your surgery. This needs to be done 1-2 days before your operation. During normal office hours you will not need an appointment. You will not need to fast and the results will be sent directly to Dr Onuma, your GP and the hospital so you will not need to wait for any results.
  
  
• If you are on blood thinning medications (aspirin, warfarin etc) these will need to be stopped some 7-10 days prior to surgery. Please note that some herbal remedies/”natural” do cause blood thinning, so if in doubt STOP using them. Discuss with Dr Onuma as required.
  
  
• If you have been advised of the need to have bowel preparation then please read the separate document provided. You will usually only need one sachet of Picolox or ColonLYTELY (obtained over the counter from the chemist). There are 2 sachets in each box. You might find that the preparation is not effective until the early hours of the morning; this is normal. The preparation may still be working on your admission to hospital; this is normal.
  
  
• Please arrive at the hospital at the time indicated on your admission forms.
  
  
• Please note the fasting times on your admission forms. Milk is considered to be a food. o You will usually see your anaesthetist on the ward before being transferred to the operating theatre.
  
  
• You will usually see Dr Onuma either in the waiting area or in the operating theatre prior to surgery. o Anticipate going home from hospital the day of surgery or being in hospital overnight or after 2-4 nights. If you go home the same day you need a responsible adult to be with you overnight.
  
  
• TED stockings (elasticated) will be fitted for you by the nursing staff before you come into the operating theatre. You must be wearing them otherwise you may not be allowed into the operating theatre. By improving the flow of blood from the legs back to the heart they reduce the risk of DVT (deep vein thrombosis) and PE (pulmonary embolus). You will need to wear the TEDs until you get home. Once you are at home you will no longer need to wear them as long as you are mobile. If you fly within 6 weeks of surgery you are advised to wear them for the flight.
  
  
• Clexane: by thinning the blood, Clexane reduces the risk of DVT and PE. Thinning the blood also increases the risk of bleeding and being returned to theatre to control bleeding. Nevertheless, prevention of DVT/PE is very much more important. The first injection will usually be given towards the end of the surgery or occasionally delayed until you reach the recovery area or ward. The nursing staff will give you an injection everyday until you go home. o You will receive antibiotics into the vein whilst under anaesthetic.
  
  
• If you have had MESH (excludes tapes used for urinary incontinence) inserted into the vagina or pelvis then you are likely to have intravenous antibiotics for a period of 24 hours.
  
  
• Sometimes the final decision to use mesh in the vagina for extra support will be taken during surgery.
  
  
• During your operation you will receive painkillers either as an injection into the vein or as suppositories in the rectum. You will be written up for painkillers and anti-emetics whilst on the ward. Do not hesitate to request these from the staff as required.
  
  
• You will have a drip in your hand through which you will receive fluids into the vein. This will cease when you are drinking enough by yourself. PTO o If you have had incontinence ± prolapse surgery you are likely to have a catheter ± vaginal pack sited. These will usually come out the day after surgery.
  
• Some patients who have had laparoscopic (keyhole) surgery may have a drain left in the abdomen to remove excess gas or fluid (this decision is made during surgery). For patients going home on the day of surgery this will be removed before discharge. For inpatients the drain is usually removed the following day.
  
  
• Dr Onuma will be happy to phone one relative of your choice when the surgery is finished. If there is no answer on the number provided, Dr Onuma will leave a simple message, if there is such a facility, but will not attempt to phone again.
  
  
• If you have had incontinence ± prolapse surgery, the nursing staff will check the amount of urine you pass and the amount left in the bladder (with a portable scanner) once the catheter is removed. They have a specific guide (copy provided for your information) as to how to do this and will phone me if they have any concerns.
  
  
• If you have had complex laparoscopic or open surgery then you will be on a soft diet after your operation until you are passing flatus.
  
  
• Admission to hospital involves a change in diet, fluid intake and environment. Many women will find that they have a temporary change in bowel habit, most often tending towards constipation. Dr Onuma generally prescribes Coloxyl with Senna, 2 tablets each evening from the day after surgery. If you have a tendency towards constipation and there is a particular product that works best for you then bring it into hospital with you and Dr Onuma will assess whether you can continue with it during your admission instead of using Coloxyl with Senna. You are not required to have emptied your bowels prior to your discharge from hospital.
  
  
• Pelvic reconstructive & investigative surgery are commonly associated with some blood loss. Excessive bleeding requiring transfusion is an uncommon but known risk of surgery. Dr Onuma would only transfuse you with blood if he thought it to be absolutely necessary. If you are a Jehovah’s Witness please provide the appropriate signed documents relevant to acceptance of blood products before your admission to hospital.
  
  
• The loss of small amounts of vaginal blood following surgery is normal. Some women will get an extra ‘gush’of blood between 7-14 days after surgery. This is also not unusual. If you feel that the loss is excessive then contact Dr Onuma‘s staff. They will arrange for you to be seen earlier. If you have an offensive loss then you must contact Dr Onuma‘s staff as you are likely to require a course of oral antibiotics.
  
  
• Pudendal nerve block; an injection given into the vagina to decrease pain related to your surgery. Such an injection may delay the ability to empty the bladder between 4-12 hours. If this occurs an indwelling catheter may be required overnight. o It is not uncommon to suffer from bloating/cramping of the abdomen with associated discomfort after keyhole or open surgery. This tends to happen more often in women who suffer from irritable bowel syndrome. This may take several weeks to settle completely. Occasionally tablets to help settle the bloating/cramping may be required.
  
  
• Dissolvable sutures are used in vaginal repairs and closure of abdominal wounds. Sometimes they may need to be removed, particularly if there has been a minor infection. When they do not dissolve spontaneously then can become brittle. o Please remove your abdominal wound dressings 5 days after surgery.
  
  
• Recommence using Vagifem/Ovestin 2/3/4/5/6 weeks after surgery. o Recommence using Ditropan/Vesicare/Tofranil when you get home from hospital.
  
  
• Whilst you may be a passenger in a car, your insurance will not cover you to drive for 24hrs following most day case surgery or 1-2 weeks after most inpatient procedures (4-6 weeks if you have had open surgery). If you have any doubts then please discuss with Dr Onuma. o Post surgery follow-up will be arranged for you at the time of your consents for surgery.
  
  
• Dr Onuma is happy to provide a ‘Sick Certificate.’ He can only provide you with this from the time of admission not beforehand. If you require a certificate then make the request to Dr Onuma’s staff and provide them with the required dates. Where necessary, ‘Carer’s leave’ certificates can also be provided.

Information Regarding Your Planned Surgery With Dr. Onuma

Kindly read this document carefully. It concerns events related to your admission to hospital for surgery. If there are any aspects of your admission or surgery that you are unclear about then you should approach Dr Onuma or his staff for clarification.

Your operation has been booked at: 'Specified' HOSPITAL

On: ……/………/……..

Your date of admission to hospital is: ……/………/…….. at: …………………..

• Please DO NOT EAT ANY FOOD after ………………. OR DRINK (water/black tea/black coffee only) after ………………… **If you are not correctly fasted for your anaesthetic, the operation may be cancelled or postponed until you are correctly fasted.
  
  
• If you are taking regular medication, continue to do so (unless otherwise instructed by Dr Onuma). Take all medications with a very small sip of water. Aspirin, Warfarin and other blood thinning drugs must be stopped at least 7 days prior to your surgery (*discuss with Dr Onuma).
  
  
• If you do not understand the nature of your operation or the possible complications of the procedure, you should arrange to see Dr Onuma again prior to the date of surgery.
  
  
• Patients are often surprised by the number of accounts that they may receive following admission to hospital. These can sometimes cause confusion and distress if people are not aware. Following surgery you may receive an account from the following:
  • The Hospital, which will include a bed fee, theatre fee and a fee for any disposable items and surgical implants used in the operation. If covered by Private Health Insurance, you should check the level of cover and the amount of rebate with the Insurance Company and the Hospital.
    
    
  • Assistant. An assistant is required for all major cases and some intermediate cases. You will be informed if an assistant is required and the likely gap for this service. Assistant required / not required. GAP: Yes / no. $.....................
    
    
  • Anaesthetist. You will receive a guide outlining the likely schedule of fees from the anaesthetist. Should you have any questions then you are advised to phone the anaesthetist directly.
    
    
  • Investigations: including blood tests and testing of tissue samples will be charged by the company concerned to your medical benefits fund. There may be gaps for some of these services.
    
    
  • Dr Onuma charges a gap, the level of which will be related to the duration and/or complexity of your surgery. Kindly note that the payment of this sum is your responsibility. *This gap is payable prior to your surgery. Your ‘gap’ is $..................... Due by …... / …… / … If you have any particular queries regarding any aspect of these matters please ask us, or your health insurer.

  I hope this information is of assistance to you in preparation for your surgery.

For Patients Undergoing Day Case Surgery

• Day case surgery implies that you will go home on the day of your surgery.
  
  
• Occasionally, after day case surgery, the requirement for pain relief or anti-nausea medication may necessitate an overnight stay in hospital.
  
  
• It is unlikely that Dr Onuma will talk to you about your surgery before you leave the hospital. This is because:
  • Most people do not remember the detail of conversations made shortly after they have had an anaesthetic.
    
    
  • Tissues samples may have been sent to the lab for analysis. The results of these may be an important factor in the discussion about the outcome of surgery and any further management required.
    
    
  • As you have waited to have your surgical procedure, there are likely to be other patients waiting to have their surgery. Dr Onuma prefers to continue operating so that the waiting time of other patients is kept to a minimum.
• For these reasons you will almost always have a follow-up appointment to be reviewed, to discuss the outcome of this surgery and any further changes to the management of your condition.
  
  
• It is important that a responsible adult collects you from the hospital after your surgery and preferably is in a position to keep an eye on you overnight.
  
  
• For at least 24 hours after your surgery:
  • Do not drive a motor vehicle. Police prosecution may result, and your insurance may not cover you.
    
    
  • Avoid alcohol or sedative drugs that have not been authorised by your surgeon or anaesthetist.
    
    
  • Avoid making important decisions or signing important documents.
    
    
  • Do not cook or use machinery. This includes operating household appliances such as a washing machine.
    
    
  • Do not engage in sports, heavy work or lifting.
    
    
  • Do not travel alone or by public transport.

If you have any questions as to any aspects of the information provided above, please discuss with Dr. Onuma prior to your surgery.

Deep Venous Thrombosis(DVT)

• As the world becomes more globalized and traveling becomes easily accessible to most people, we face diseases that may result from travel. Deep Venous Thrombosis (DVT), also referred to as Venous Thromboembolism (VTE), is undoubtedly a disease that can be deadly for an individual.
  
  
• DVT results from many factors that can easily occur in travelers during flights lasting longer than 3 hours. Although the risk of DVT is not very high, occurring generally in about one in every six thousand people, risk factors such as age, obesity, pregnancy, smokers or people who have had certain surgical procedures like hip or knee replacements, or abdominal surgeries may increase the risks of DVT.
  
  
• Some cancers such as lung, ovarian and breast cancers have been shown to increase the risks as well as anyone having undergone chemotherapy. Certain heart conditions, high blood pressure or cardiovascular disease, bowel diseases and other gastrointestinal conditions can increase the risk as well.
  
  
• A prime candidate for DVT might be also be a person with varicose veins who takes a flight longer than 3 hours in an air-conditioned environment that causes dehydration, who failed to ingest liquids, thereby avoiding frequent bathroom visits.
  
  
• DVT results from a blood clot in the deep veins of the lower extremities, producing intense pain in the calves and extreme swelling in the limbs. This swelling may progress from the feet up to the thighs. This phenomenon may not appear for up to 48 hours after a trip. Although there is an immediate concern of pain and swelling, blood clots are not the real causes of concern per se. However, if a clot in a vein breaks off and travels to the arteries of the lung in the form of a pulmonary embolism, this may quickly lead to death or may result in many serious complications that require immediate hospitalization in the Intensive Care Unit.

  The following recommendations are specifically designed to prevent DVT:

• The day before traveling:
  • Make sure you walk throughout the day. This should not be difficult since you likely have many errands to run before your trip.
  • Do not forget to take the medications you usually take but if you regularly use a diuretic, ask your doctor if you can skip it just for this day before travel in order to avoid dehydration.
  • Take a lot of fluids 24 hours before the trip.
  • The use of anti-clotting agents (anticoagulants) or anti-platelet agents must only be used as indicated by the treating physician.
• The day of travel:
  • Make sure you use comfortable, loose-fitting clothing that is not tight around the waist.
  • Avoid using high-heeled shoes to prevent swollen feet.
  • Make sure you take liquids throughout the day so your bloodstream can become thinner, forcing you to get up and walk to the bathroom during the flight.
  • Avoid postures that obstruct blood flow back from your legs such as sitting with your legs bent or crossed.
  • Make sure that you walk frequently along the aisle at least every 3-4 hours.
  • If your legs are prone to swelling, elastic socks are recommended.
  • Stretching exercises are recommended, such as standing on your heels or toes.
  ***If you have suffered previously from leg thrombosis, ask your doctor if you should take any additional precautions.

Anaesthesia for Vaginal Hysterectomy, Vaginal Repair (Where Laparoscopic Surgery Is Not Involved) And TVT Procedures For Urinary Incontinence.

Prepared by Dr Paul McAleer Specialist Anaesthetic Services Adelaide, South Australia

What choices of anaesthesia do I have?

• Your options for anaesthesia will depend to some extent on the type of surgery you are having. Broadly speaking you can have a general anaesthetic, a regional anaesthetic, or local anaesthetic with sedation.
  
  
• What are the differences?
  • General anaesthesia means you are completely unconscious and unaware during your operation.
  • Regional anaesthesia means one part of your body is made numb so that you don’t feel the surgery. This usually means you have an epidural or spinal anaesthetic.
  • You can also have sedation so that you sleep lightly during your operation. Local anaesthetic can also be used to numb just one tiny part of skin, but this choice is not suitable for most major operations.
• What is spinal anaesthesia?
  • Spinal anaesthesia is a common way of providing good, safe anaesthesia for many operations, and is especially suited to vaginal surgery.
  • Spinals are similar to epidurals, but have some significant advantages.
  • Spinals are usually easier to insert, work much more quickly and are more reliable than epidurals.
  • Having a spinal involves an injection in your lower back, into the spinal fluid, of a small amount of local anaesthetic. A few minutes afterwards, you become numb from the waist down. Your legs will also get very heavy. You can then have your surgery in complete comfort.
  • What are the advantages of a spinal over a general anaesthetic? There are numerous small factors, which add up to make spinal anaesthesia a good choice.
    • General anaesthesia will make you feel tired and sleepy for several hours afterwards. Nausea and vomiting is common after general anaesthesia, but much less of a problem with a spinal.
    • Control of your pain is usually easier after a spinal, and we have noticed that women who have a spinal tend to get up and out of bed sooner, and are more comfortable.
    • There is probably a reduction in the amount of blood lost during surgery, and the risk of a deep vein thrombosis, a potentially serious complication of any surgery, is less after spinal anaesthesia.
    • If you have any other serious health problems, such as heart disease, asthma, emphysema, diabetes or blood pressure, then the benefits of spinal anaesthesia are even greater.
• Do I have to be awake during the operation?
  • No, you don’t. You will be offered some sedation to let you sleep lightly during the operation.
  • The amount of sedation you have can easily be adjusted to your needs, so that you can be almost completely unaware of the surgery, or just calm and drowsy, its up to you.
• But aren’t there some serious risks from spinals?
  • Yes there are, but serious problems after spinals are very rare, and don’t forget that serious problems occur with general anaesthesia too.
  • Common side effects from spinals are the chance of a slight backache afterwards, which is usually only a minor short-term problem.
  • Your blood pressure commonly falls a bit during the operation, but your Anaesthetist will monitor and correct this as necessary.
  • There is a small chance of developing a bad headache afterwards, called a spinal headache. This is usually self-limiting and easy to treat, but very occasionally persists for several days.
  • Serious complications include the risk of infection or bleeding around the spine, and the possibility of damage to nerves causing permanent disability. It is true that these things do happen, but they are extremely rare, and probably rarer than the serious complications of general anaesthesia.
• Can everyone have a spinal?
  • No, there are some reasons why it not safe for some people to have a spinal.
    • If you are taking medications to thin the blood, like warfarin, then unless these medications are stopped well before surgery (which is not always advisable) the risk of bleeding into the spine is too great.
    • There are also some back problems that make spinals difficult or impossible. However just because you have a back problem does not mean that you can’t have a spinal.

How can I find out more before my operation?

• If you are still unsure about what type of anaesthetic to have, your Gynaecologist can arrange for you to see your Anaesthetist well before surgery to help you decide. Just ask how to make an appointment to see your Anaesthetist.