Dr Aruku Naidu












TEL: 605-2408777
EMAIL: aruku1964@gmail.com, aruku64@hotmail.com


Patients can present with swelling or masses  around urethral meatus ( Peri urethral or Para urethral swelling). The incidence has been reported to be less than 4%. They can present with various symptoms, including symptoms of voiding dysfunction, mass feeling/prolase feeling & sexual dysfunction. Over 25 years l have seen various from of the swelling & masses. Some of this are cystic in nature, abscess & some are firm masses, rarely malignant.The masses that l have seen are usually simple skene gland cyst,  skene gland abscess, inclusion cyst, Gartner’s/Mullerian duct cyst, fibroma, angiofibroblastoma, granuloma or in rare cases malignancy neoplasma of urethra or vagina. The para urethral mass can be confused to urethrocele, cystocele, urethral diverticulum urethral proplase, ectopic uretrocele & caruncle some cases.

DDX of para/ peri urethral mass/swelling study base on 1,950 patients by author 1. It was also extensively discussed by the author 2. please read them for further understanding.

  1. urethral diverticula-84%
  2. Vaginal cysts histologically identified as fibromuscular tissue-7%
  3. leiomyomata-5%
  4. ectopic ureteroceles-2.5%
  5. vaginal squamous cell carcinomas-2.5%
  6. infected granuloma

I am sharing some of my experience in managing selective cases as below. All these pictures shown below are some of the cases managed by myself. Permission has been obtained to exhibit these pictures for learning purposes,

Skene glands, also called periurethral or paraurethral glands, are located around the opening of the urethra. Skene gland cyst or abscess is the most common paraurethral swelling l have seen in my urogynaecology practice. The glands may be involved in sexual stimulation and produce lubrication for sexual intercourse. The cyst is formed  when the duct to the gland is blocked, usually because the gland is infected. If cysts become infected, they form an abscess. Symptoms: Most cysts are less than 1 centimeter in diameter and usually asymptomatic. Large cyst can cause pain during intercourse,  voiding dysfunction & irritative lower urinary tract symptoms or incontinence .  Infected cyst cause abscess. Diagnosis is based on patients symptoms, through pelvic examinations & sometimes by performing pelvic ultrasounds or cystoscopy.


suburethral abcess

Suburethral Abcess

The treatment depends on the nature of the mass. For simple skene gland cyst, cystectomy or marsupilization can be carried out. For an abscess, masupialization is preferred compared to incision & drainage. The recurrence rate is very high following I & D. Creating a permanent sinus will prevent future recurrences. What need to be done is to do an elliptical incision, drain the pus, wash out the cavity & apply interrupted sutures in circular pattern as we do for Bartholin abscess. we can pack the cavity with ribbon gauze for a day. Post operative cover them with antibiotics. Do check for diabetes. most of them recover very well by one week.





suburethral abcess

suburethral abcess






suburethral cyst




skene gland cyst

The mass usually appears cystic & slow growing over few months to years. The treatment is either cystectomy or marsupialization. care has to be taken to avoid injuries to the urethra. Insertion of cather & post op cystoscopy is essential.




paraurethral finroma


Suburethral Fibroma/ Leiomyoma

The treatment  fibroma/ leiomyoma/ fibroblastoma needs complete enucleation or excision of the fibroma, care has to be taken to avoid urethral injury. Insertion of a catheter may help to delineate the anatomy.  Infiltration of normal saline or marcaine/adrenalin may reduce excessive blood loss.  The enucleated cavity is tightly close to prevent haematoma.






Angiomyofibroblastoma is a rare mesenchymal tumour, it usually appears as painless lump. It a slow growing of a benign in nature. Some angiomyofibromas can be reported as aggressive angiomyxoma, this variety affects deeper tissues with infiltrative margins. this form tends to recur. The outcome in these patients is good, and always favourable with simple excision of the tumour mass.



paraurethral gartner cyst


Gartner’s cyst

Para urethral Gartners’s cyst can present with small cystic swelling to a large & extensive swelling. Treatment is cystectomy if it is small & l prefer to do marsupialization if it’s very large and extending deep to pelvis. l have seen two such extensive cyst. Both this patient had marsupialization & drainage of the content. Both these patients recovered very well. They only had small sinus in the inner aspect of vaginal & it was not noticeable.




urethral prolapse


Ectopic ureter

This young 15 year old patient presented with continuous urinary leakage since young. On examination there were continuous clear urine drainage from the peri-urethral area. CT-U was done reveal an ectopic ureter from the right kidney till the periurethral area. The ectopic ureter was ligated by the pediatric surgeon. Following the surgery patient remain dry 7 well.





periurethral sq ca


periurethral sq cell ca

56 year old patient presented with urinary obstruction & pv bleeding. Histology was consistent with sq cell ca. She has been refered for radiotherapy









Refenences: :

  1. Periurethral masses: etiology and diagnosis in a large series of wowen. Obstet Gynecol. 2004 May;103(5 Pt 1):842-7
  2. Benign masses of the female periurethral tissues & anterior vaginal wall, Sophie G et al, Current urology reports 2008, 9:389-396
  3.  Female paraurethral cysts: experience of 25 cases. SHARIFI-AGHDAS and N. GHADERIANUrology-Nephrology Research Center,  Labbafi Nejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  4. An unusual vaginal mass. A case of paraurethral angiomyofibroblastoma. Aruku Naidu et al  Australian & New Zealand Journal of Continence. Vol: 10, Number 1, March 2004
  5. Urethral Leiomyoma: A Rare Clinical Entity. Beng Kwang N, Naidu A, Yahaya A, Pei Shan L. Case Rep Surg. 2016;2016:6037104. doi: 10.1155/2016/6037104.





A 65 year old otherwise healthy woman presents with incontinence of urine on coughing, sneezing and laughing.

a)What important aspects in history will influence your subsequent management? 8 marks

b)What investigations would you perform and how would you manage her?12 Marks



-severity of incontinence and the impact on quality of life (QOL)*IMPORTANT

-other urinary symptoms; urgency, urge urinary incontinence, frequency, nocturia

-symptoms of voiding dysfunction; dribbling, hesitancy, poor stream, strain to void

-UTI symptoms; dysuria, haematuria, frequency

-Presence of bladder pain and prolapse symptoms

-Bowel symptoms- constipation, incontinence of faeces

-Past obstetric history including date of last delivery and reproductive intentions

-Fluid intake, caffeine, alcohol

-Previous treatment for incontinence including surgery


Key point here is ‘healthy woman’


Urine dipstick

Mid stream urine for culture

Bladder diary/ Frequency volume chart

Multichannel urodynamics only if conservative treatment has failed or if surgery is being considered or before surgery if there is clinical suspicion of DO/ previous surgery for SUI or anterior compartment prolapse/ symptoms of voiding dysfunction

Management include an examination (BMI, abdominal and pelvic examination; pelvic mass, palpable bladder; Check for presence of prolapse; Demonstrate SUI with moderately full bladder, 150mls)


  • Life style intervention: reduce weight, quit smoking, reduce/avoid risk factors, control medical disorders like asthma
  • Application of oestrogen cream/gels-controversial, there are some evidence that has shown , reduction in all type of incontinece
  • First line treatment should be supervised pelvic floor exercise/ muscle training (PFMT) lasting at least 3 months, there good evidence shown significant reduction in the incontinence esp. GSI ( 65-70%)
  • Duloxetine should not be used as first line treatment or should not be routinely used as a second-line treatment for SUI. (NICE guidelines)

Surgical options if conservative treatment failed;

–          retropubic mid-urethral tape ( Subject. & Object cure rate 85-95%)

–          open colposuspension (Subject. & Object cure rate 85-95%)

–          TOT

–          Intramural bulking agents

–          Artificial urinary sphincter

Not recommended for SUI;

–          Routine use of lap colposuspension

–          Anterior colporrhapy, needle suspensions, paravaginal defect repair, MMK procedure

–          Autologous fat and PTFE as intramural bulking agents



A 58 year-old woman has had a TAHBSO 3 years earlier for uterine fibroids and now complains of ‘something coming down’ her vagina. Examination reveals a vault prolapse and a moderate cystocoele.

How would you manage her? (Key word here is MANAGE; which would include history, examination, investigation, treatment)

  1. History

Clarify nature of symptoms, worse with standing/ standing, relieved by lying down

Effects on quality of life

Urinary symptoms- any incontinence, incomplete voiding, voiding difficulties (symptoms likely to be related to prolapse)

Bowel symptoms- incontinence, difficulty emptying rectum (URINARY AND BOWEL symptoms comes hand in hand)

Sexual history and desire to retain sexual function

Previous gynecological history especially on the hysterectomy/ prolapse surgery

  1. Examination


Any abdominal mass

Speculum examination; using the objective assessment of prolapse with POP-Q

Access for SUI after reducing prolapse with full bladder

Pelvic examination (the Bimanual- to assess for pelvic mass)

  1. Investigations

Relevant blood investigations eg FBC, Renal Profile, pre-operative work up

  1. Treatment options

Non-surgical options

-Pelvic floor exercise – no evidence for efficacy, used in women whom wants to avoid surgery but maintain sexual function, unlikely to be effective

– Pessaries- ring/shelf (with the ring, likely to be expelled in women with deficient perineum/perineal body. With shelf pessary, sexual intercourse may not be possible). Should be reserved for women who are unfit/decline surgery or while awaiting surgery. Need to be changed every 6-9 months.

Surgical options

–          Abdominal sacro-colpopexy- effective, evidence proven, major surgery for a relatively healthy women but may require the additional vaginal procedure if woman has anterior/posterior vaginal wall prolapse

–          Sacrospinous ligament fixation – vaginal procedure with lower morbidity and suitable for women who are unfit for laparotomy. Failure rate higher than abdominal route. Allows simultaneous vaginal wall repair.

–          Laparoscopic sacro-colpopexy may be undertaken if expertise is available

–          Colpocleisis may be offered for frail women who do not wish to retain sexual function.

–          Mesh- controversial and probably should not be mentioned in an exam answer as the only evidence for it would be anterior repair.

Three cases of paraurethral angiofibroblastoma

Untitled 1

Three case reports of angiofibroblastoma.

Case 1

32 year old lady presented with an asymptomatic, but gradually enlarging
vaginal lump over 3 months. On examination, there was a small 3×2 cm rubbery
tissue mass arising from the left paraurethral region. An examination under
anesthesia and excisional biopsy was thus organized. However she defaulted
on her surgery due to anxiety, and failed to attend her follow up
appointment. Six months later she returned complaining od pain and bleeding
on voinding. On examination, the solitary paraurethral lump had noe enlarged
to a size 8x8x4 cm, amd had become ulcerated and infected ( figure 1). There
was no associated inguinal lymphaadenopathy. Due to the pain and voiding
difficulties, an examination under anesthesia, cystoscopy and excision of
the mass was promptly carried out. Intraoperatively, the tumour was found to
be localized to the paraurethral regionand had not invaded into the urethra
or bladder. It was found that the tumour was well circumscribed and was able
to be ‘shelled out’ relatively easily. The patient did not require any
indwelling catheter post operatively and subsequently made an uneventful
recovery ( figure 2). Histopathology confirmed the mass to be a benign

Case 2.
A 42 year old Para 2+1,  This patient
initially presented on 9.10.2008 because she noticed a mass per vaginal
which had been present for 2 years, it was reducible but protruded back out
immediately. The mass was firm, nodular and mobile, measuring 4×3 cm. The
mass progressive got bigger and causing voiding dysfunction.  An examination
under anesthesia was carried out on 226.2009. An indwelling catheter was
inserted to assist in the surgery. The mass was very close to the urethra
and has distorted the anatomy of the urethra. The mass was easily
enucleated.  The estimated blood loss was 100mls. There were no
intraoperative complications. The catheter was kept for three days. The
histology was consistent with suburethral angiofibroblastoma (4x3cm).

Case 3.

This a 65 year old lady Para 6, presented
with elongated and firm mass near the urethral meatus. The mass was
initially small but over six year its size has increased and causing pain
and difficulty in walking. She also has difficulty in micturation. She has
to move the elongated mass to one side. On examination there was a 7x4x4 cm
elongated mass with the tip of the distal part of the mass appeared
fungating and necrosing. The proximal part of the mass had a 4cm stock/
base. She underwent examination under anaesthesia and excision of the mass.
The surgery was straight forward. Check cystoscopy was normal. The histology
was consistent with    Angiomyofibroblasroma.

Angiomyofibroblastoma is a rare mesenchymal
tumour of the female genital tract that was only first described in 1992(1).
This tumour is predominately found in the vulval region, bu can also arise
from the vagina, clitoris, labia majora and perineum. Unusual cases
involving the male scrotal and inguinal regions have been reported 9(1).
They have been reported in women from the age of 23-86 (mean 45.8) years.
They usually appears as a painless lump that may have been present for a few
weeks or up to 13 years. Clincally, this tumour can be mistaken for a
bartholin gland cyst, skene’s gland cyst, urethral diverticulum or Gardner
duct cyst.
Angiomyofibroblastoma is a slow growing
tumour that is usually well circumscribed, and has a soft rubbery
consistency with a bulging, pink, section surface. Histologically, this
tumour is composed of two components: the blood vessels and stromal cells.
It shows alternating hypercellular and hypicellular oedematous ares, in
which numerous thin walled, small to medium sized vessels are irregularly
distributed throughout. The tumour cells show immune reaction for vimentin
and desmin and , more recently, it was noted to be muscle
specificactin-positive or Alfa-smooth muscle actin-positive (2,3,4). It is
typically benign in nature. Only one case of a malignant transformation of
an angiomyofibroblastoma ( ‘angiomyofibrosarcoma’) has been reported(3).
Angiomyofibroblasroma may have been reported
as an aggressive angiomyxoma. Unlike Angiomyofibroblasroma, aggressive
angiomyxoma affects deeper tissues with infiltrative margins, and tends to
recur (4). The pathogenesis of Angiomyofibroblasromais still unclear,
although it has been proposed that it may originated from an immature
mesenchymal cell in the sub epithetial myxoid zone of the lower female
genital tract, or in perivascular areas. The outcome in these patients were
good, and is always favorable with simple excision of the tumour mass.

    Fetchers CDM, Tsang WY, Fisher C, lee KC & Chan JK.
    Angiomyofibroblasromaof the vulva. A benign neoplasm distinct from
    aggressive angiomyxoma. Am J Surg Patho 1992; 16;373-82.

  1. 2.

    Hiroshi K, Noriomi M, Yoshikazu S, Masanori M, Taiji T &
    Takashi s. Angiomyofibroblasroma of the female urethra. Int J Urol 1999;
  1. 3.  
    ielsen GP,Young RH, Dickersin GR & Rosenberg AE.
    Angiomyofibroblasromaof the vulva with sarcomatous transformation
    (‘Angiomyofibrosarcoma)’. Am J surg Pathol 1997;30:3-10
  1. 4.    
    Steeper TA & Rosai J. Aggressive angiomyxoma of the female pelvis
    and perineium. Report of nine cases of a distinctive type of
    gynaecologis soft-tissue neoplasma. Am J Surg Pathol 1983; 7:463-465.
  1. 5. 
    Fukunaga M, Nomura K, Matsumoto K, Doi K, Endo Y & Ushigome S.
    Vulval Angiomyofibroblasroma: Clinicopathological analyisi of six cases.
    Am J clin Pathol 1997; 6:45-51


Vaginal Discharge

Vaginal discharge is a common presenting symptom in any physician’s office. Vaginal discharge may be physiological or pathological. Although abnormal vaginal discharge often prompts women to seek screening for sexually transmitted infections (STIs), vaginal discharge is poorly predictive of the presence of an STI.1Clinicians need to be aware of emerging epidemiological data, the different presentations of vaginal discharge, and how to approach their management so that the symptom can be treated according to its aetiology.2

Vaginal discharge is a common gynaecological condition among women of childbearing age that frequently requires care. It derives from physiological secretion of cervical and Bartholin’s glands and desquamation of vaginal epithelial cells resulting from bacterial action in the vagina.3The amount of mucus produced by the cervical glands varies throughout the menstrual cycle. Vaginal discharge that suddenly differs in colour, odour, or consistency, or significantly increases or decreases in amount, may indicate an underlying problem like an infection.4 Increased amount of vaginal discharge can be due to emotional stress, ovulation, pregnancy or sexual excitement.


Physiological Discharge

Many women have what they perceive as an abnormal vaginal discharge at some point in their lives, but usually it is just a normal physiological discharge. This is a white or clear, non-offensive discharge that varies with the menstrual cycle. The quality and quantity of vaginal discharge may alter in the same woman in cycles and over time. Factors that can influence physiological discharge are:-
1)      Age

  • Prepubertal
  • Reproductive
  • Pregnancy
  • Hormonal contraceptions
  • Menopause

2)      Local facors

  • Semen
  • Personal hygiene and habits
  • Menstruation

Pathological Discharge

Pathological vaginal discharge can be further divided by specific age groups which are prepubertal group, reproductive group and menopause group.

Common causes of pathological vaginal discharge for each age group are:-

Prepubertal Reproductive Menopause
Nonspecific bacterial vaginitis Foreign bodies (ex: IUCD, tampon, condom) Cervical or endometrial carcinoma
Foreign bodies Allergic to local irritant Actropic vaginitis
Sexual abuse Infections FB (ex: vaginal pessary)

Common causes of infections:-

  • Candidiasis: Acute vulvovaginal candidiasis / recurrent vulvovaginal candidiasis
  • Bacterial vaginosis
  • Trichomoniasis
  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Pelvic inflammatory disease

Principles of management
1)      History5

  • Characteristics of the discharge – Onset, duration, colour, odour, consistency.
  • Any associated symptoms – Itch, dyspareunia, abdominal pain, abnormal vaginal bleeding or pyrexia is more likely to indicate sexually transmitted infection.
  • Sexual history – Is patient at increased risk of sexually transmitted infection (age <25 years, new sexual partner or more than one sexual partner in past year, previous sexually transmitted infection)
  • Contraceptive use
  • Pregnancy
  • Concurrent medications and previous treatments
  • Medical conditions such as diabetes, immunocompromised state.
  • Non-infective causes of discharge such as allergic reaction, known cervical ectopy or polyps, genital tract malignancy, foreign body (such as tampons).

2)      Examination5

  • Abdominal palpation for tenderness or mass.
  • Inspect the vulva for discharge, erythema, ulcers, other lesions or skin changes.
  • Bimanual pelvic examination for adnexal or uterine tenderness or mass, and for cervical motion tenderness (this can indicate pelvic inflammatory disease).
  • Speculum examination to inspect vaginal walls, cervix, and characteristics of discharge.
  • Take endocervical swabs if there is risk of sexually transmitted.
  • High vaginal swabs are of limited diagnostic value except in pregnancy, post-instrumentation, failed treatment, recurrent symptoms, or to confirm candidiasis.

Bacterial Vaginosis

Bacterial vaginosis is the most common cause of infective vaginal discharge. It causes profuse and fishy smelling discharge without itch or soreness. This condition is characterised by an overgrowth of anaerobic bacteria and occurs and remits spontaneously. Asymptomatic bacterial vaginosis in non-pregnant women does not require treatment. The condition is associated with poor pregnancy outcomes, endometritis after miscarriage, and pelvic inflammatory disease. Antibiotics are the mainstay of therapy for bacterial vaginosis. Medications include metronidazole, clindamycin, and metronidazole vaginal gel.

Vulvovaginal Candidiasis

The prevalence of asymptomatic carriage of Candida in women is 10%. Symptoms are vulval itch and soreness and thick white non-offensive discharge. There is no evidence that combined oral contraceptives cause candidiasis. Asymptomatic vulvovaginal candidiasis does not need treatment. Vulvovaginal candidiasis can be acute or recurrent. Recurrent vulvovaginal candidiasis diagnosed when there are 4 or more episodes of VVC in 1 year.

Chlamydia Trachomatis

Chlamydia trachomatis is the most common sexually transmitted infection caused by a bacterium. Chlamydia can cause a purulent vaginal discharge, but it is asymptomatic in 80% of women. It was thought that 10-40% of untreated chlamydial infections will result in pelvic inflammatory disease. This has recently been challenged by a large observational study, which reported that only 5.6% of women developed this disease,6 and by a small prospective study that reported an even lower rate of 1%.7 Chlamydia is treated with either single dose of Azithromycin or twice daily dose of Doxycycline.

Neisseria gonorrhoea

Neisseria gonorrhoea may present with a purulent vaginal discharge but is asymptomatic in up to 50% of women. Major symptoms include vaginal discharge, dysuria, intermenstrual bleeding, dyspareunia and mild lower abdominal pain. The true prevalence and epidemiology in the general community is not known. Gonorrhoea may be complicated by pelvic inflammatory disease.Culture is the most common diagnostic test for gonorrhoea, followed by the deoxyribonucleic acid (DNA) probe, and then the polymerase chain reaction (PCR) assay and ligand chain reaction (LCR).


Trichomonasvaginalis can cause an offensive yellow vaginal discharge, which is often profuse and frothy, along with associated symptoms of vulval itch and soreness, dysuria, and superficial dyspareunia, but many patients are asymptomatic. The true prevalence and epidemiology in the general community is not known. Usually an oral antibiotic called metronidazole (Flagyl) is given to treat trichomoniasis.

Persistent Vaginal Discharge

It would be difficult to proceed further for women who complain of persistent vaginal discharge with repeated negative STI screen results. When minimal discharge is evident, it is worth discussing again personal hygiene practices and douching, the basis for physiological discharge, and inquiring whether there are psychosexual difficulties as a result of the patient’s continued symptoms.

If use of spermicides and lubricants are contributing to symptoms, alternative contraception choices should be discussed. An extensive cervical ectropion can cause heavy mucoid discharge. After the menopause, atrophic vaginal changes may predispose women to infective vaginitis. Intravaginal oestrogen replacement, with pessaries or cream, gradually improves the condition of the vaginal epithelium and reduces the susceptibility to infection.

Underlying gynaecological disease must be considered in all women with unexplained persistent vaginal discharge. Gynaecological neoplasms, such as benign endocervical and endometrial polyps, can present with vaginal discharge, and malignancy needs to be excluded.


Many women self-diagnose and self-treat episodes of vaginal infection with over the counter treatments. Some women may subsequently present with history of recurrence and never having had this diagnosis confirmed by any microbiological tests. It is important to confirm the diagnosis and to ensure a full sexual health screen has been done to exclude concurrent infection. Management of vaginal discharge requires an empathic approach with reassurance and psychological support as necessary.

1.      Vaginal discharge—causes, diagnosis, and treatment

BMJ 2004; 328 doi: http://dx.doi.org/10.1136/bmj.328.7451.1306 (Published 27 May 2004)
2.     Vaginal discharge

BMJ. 2007 December 1; 335(7630): 1147–1151. doi: 10.1136/bmj.39378.633287.80 PMCID:

PMC2099568 Clinical Review
3.      Pathological Vaginal Discharge among Pregnant Women: Pattern of Occurrence and Association in a
Population-Based SurveyTânia Maria M. V. da Fonseca,1 Juraci A. Cesar,2 Raúl A. Mendoza-Sassi,2
and Elisabeth B. Schmidt3

4.      Source: Vaginal discharge | University of Maryland Medical Centerhttp://umm.edu/health/medical

5.      Abnormal vaginal discharge

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4975 (Published 13 August 2013)
6.      Low N, Egger M, Sterne JA, Harbord R, Ibrahim F, Lindblom B, et al. Incidence of severe
reproductive tract complications associated with diagnosed genital chlamydial infection: the Uppsala
women’s cohort study. Sex Transm Infect 2006;82:212-8.

7.      Morré SA, van den Brule AJC, Rozendaal L, Boeke AJ, Voorhorst FJ, de Blok S, et al. The natural
course of asymptomatic Chlamydia trachomatis infections: 45% clearance and no development of
clinical  PID after one-year follow up. Int J STD AIDS 2002;13(suppl 2):12-8.


Untitled 1


Kegel Exercise
First published in 1948 by

Dr. Arnold
, a pelvic floor
exercise, more commonly called a Kegel exercise, consists of repeatedly
contracting and relaxing the muscles that form part of the pelvic floor, now
sometimes colloquially referred to as the “Kegel muscles”. Dr. Kegel
attempted to develop diverse exercise for the injured women’s pelvic muscle
due to childbirth or natural urinary incontinence.

The aim of Kegel exercises is to improve muscle
toneby strengthening the pubococcygeus muscleof the pelvic floor. Kegel is a
popular prescribed exercise for pregnant

women to prepare the pelvic
floorfor physiological stresses of the later stages of pragnancy and
childbirth. Kegel exercises are said to be good for treating vaginal

in women and for treating prostate pain
and swelling resulting from benign prostatic hyperplasis (BPH) and prostitis
in men. Kegel exercises may be beneficial in treating urinary incontinence
in both men and women.

Kegel exercises may also increase
sexual gratification and aid in reducing prematue ejeculation.

here are
 many actions performed
by Kegel muscles include holding in urine and avoiding defecation.
Reproducing this type of muscle action can strengthen the Kegel muscles. The
action of slowing or stopping the flow of urine may be used as a test of
correct pelvic floor exercise technique but should not be practiced as a
regular exercise to avoid urinary retention

Urinary incontinence
The consequences of
weakened pelvic floor muscles may include urinary or bowel incontinence,
which may be helped by therapeutic strengthening of these muscles. M

randomized controlled trials

by the

Cochrane Collaboration

concluded that “PFMT (Pelvic floor muscle
training) should be the first-line conservative programs for women with
stress, urge, or mixed, urinary incontinence.
2. Pelvic prolapse – The exercises are also often used to help prevent
prolapse of pelvic organs. A meta-analysis of rabdomised controlled trials
by the
Cochrane Collaboration
concluded that “(there is now some evidence
available indicating a positive effect of PFMT for prolapse symptoms and
Here’s how to do your Kegels to strengthen your
pelvic floor: Lie or sit down, whichever you prefer. You may use a pillow as
a wedge under the small of your back if you like.
Find the muscle you identified earlier and clench it, then relax. Clench
again, than relax. And so on. One clench-and-relax constitutes a repetition,
and both sides of the repetition both the clenching and the unclenching are
equally important.

You may find it difficult to do Kegels at first
if your muscles are very weak. But each repetition really will increase the
strength of the muscles, and in time, doing your Kegels will become easier

Tighten the muscle and hold
for 10 seconds, relax for 10 seconds. Do 10 repetitions to strengthen   your
slow-twitch pelvic floor muscles.


 Tighten and hold for two seconds,
relax for two seconds. Do 10 repetitions to strengthen the fast-twitch fiber
muscles. The two different basic Kegel exercises differ only in timing, not
in the process.

Effect of Kegel Exercise
1. At the last month of pregnancy, the fetus
goes down and the head puts pressure upon of the perineal region, which
causes a pain. Kegel Exercise helps to mitigate the pain by strengthening
the perineal region.
2. In case of training the ability of moving the
pelvic floor musclefreely though Kegel exercise during the period of
pregnancy, it is possible to put pressure upon the exact region at the time
of childbirth. This helps to shorten the childbirth time.
3. At the time of giving birth, it is possible
to prevent the tear of perineal region by applying the power to the region
slowly. If not Kegel exercise, sudden application of power to the region may
cause the tear of weak perineal region.
4. After childbirth, urinary incontinence may be
occurred due to the relaxation of muscle under the bladder or the rupture of
the nerve cell or muscle. In ordinary time, cough, sneezing or laughing may
cause incontinence. Kegel Exercise is useful to settle such problems
5. In case of taking a long time in natural
childbirth, the fecal incontinence may be occurred. Kegel Exercise helps to
return such the anus muscle to the normal state.
6. With steady exercises, it is possible to
strengthen the vaginal muscle and regenerate the injured cell due to
childbirth by promoting blood circulation around the vagina.
7. This exercise helps to reduce the risk of
hemorrhoids caused by constipation during the period of pregnancy or after
8. By recovering the elastic force of the
vaginal muscle, which is weakened after childbirth, it helps to increase
sexual gratification and feel orgasm intensively.
A study by Cammu et al.,
comprising a 10-year follow-up of women after pelvic floor muscle exercise
for stress incontinence, concluded that when pelvic floor muscle training is
initially successful there is a 66% chance that the favorable results will
persist for at least 10 years.
The trials suggest that the treatment effect
(especially self reported cure/improvement) might be greater in women with
stress urinary incontinence participating in a supervised PFMT programme for
at least three months. It also seems that the effectiveness of PFMT does not
decrease with age: in trials with
urinary incontinent older women it appeared that results for both primary
and secondary outcome.

There is evidence for the widespread
recommendation that pelvic floor muscle exercise helps women

with all types of urinary incontinence. However,
the treatment is most beneficial in women with stress

urinary incontinence alone,

Consent of Patient’s agreement for Urogynaecology & Gynaecological Investigation, Treatment & Surgery

Name:———————————-  MRN/IC NO:—————————————–

Name of proposed procedure:

  • OTHER UROGYNAECOLOGY PROCEDURES:____________________________________________________
  • HER GYNAECOLOGICAL PROCEDURES:____________________________________________________
  1. Statement of health profession: I have explained the procedure to the patient. In particular, I have explained
  1. The intended benefits: (tick where applicable)
    • To improve or resolve the symptoms of ‘stress urinary incontinence’ and ‘prolapse‘
    • To remove uterus to overcome uterine related pathalogy
    • Others (please specify) ________________________________________________________
  1. Possible serious risks:
    • Damage to the bladder and/or Ureter and/or long term disturbance to the bladder function

inapproximately 2% of cases

  • Damage to bowel in approximately in 1% cases
  • Haemorrhage requiring blodd transfusion in about 2-3% cases
  • Return to the operating theatre for additional stitches or to control bleeding or for open surgery
  • Pelvic abscess/infection approximately in 1% cases
  • Venous thrombosis or pulmonary embolism approximately in 1% patients
  • Dyspareunia ( painful sexual intercourse)
  • Failure to achieve the desired results or recurrence of prolapse or urinary incontinence
  • Sling complications eg. Erosions, mesh protrusion in about 0.7%

3.Possible frequently occurring risks:

  • Urinary retention in about 3% of patients, may need excision of the tape if unable to void properly
  • Vaginal bleeding, discharge or infection
  • Frequency of micturition, nocturia and urgency in about 7% of patients
  • Wound infection – up to 15% especially in patients with risk factors
  • Pain, may require analgesics
  1. Any extra emergency procedures which may become necessary during the procedure:
    • Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure
    • Removal of ovaries for unsuspected disease during the surgery
    • Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder ,ureter, bowel or major blood vessels in approximately 4%- 8% cases
    • Other procedures (please specify) ___________________

I have explained that in obese women those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the quoted risks may be higher.

I have also discuss the benefits and risks of any available treatments including physiotherapy, ring pressary insertion and also option of no treatment

Signature:_____________________________________             Date:_____________________


Consultant Urogynaecologist

Signature of patient: ____________________________                Date:_____________________

Patients Name:_________________________________

  1. Statement of interpreter (where appropriate)

I have interpreted the information above to the patient to the best of my ability and in a way which I believe she can understand.

Signature:_____________________ Name:_______________________________ Date:______________

  1. Statement of patient

Please read this form carefully. You must also read the front page carefully which describes the benefits and risks of the proposed treatment. if you have any questions, please ask us as we are here to help you. You have the right to change your mind at any time, including after you signed this form.

  1. I have read the previous sheet and understood the benefits                                 YES            NO

and the risks of the proposed treatment or surgery


  1. I agree to the procedure described by the doctor                                                    YES            NO
  1. I understand that you cannot give me a guarantee that a particular person                 YES            NO

will perform the procedure. The person will, however has the

appropriate experience to perform the surgery.

  1. I understand that I have the opportunity to discuss the details of anaesthesia       YES             NO

with an anaesthetist before the procedure, unless the urgency of my situation

prevents this.

  1. I understand that any procedure in addition to those described on this                       YES            NO

form will only be carried out if it is necessary to save my life or to prevent serious

harm(complications) to my health

  1. I have been told about the additional procedures which may become necessary   YES            NO

during my treatment

  1. I have been given a patient information leaflet                                                                YES           NO
  1. I have listed below procedures which I do not wish to be carried out                            YES            NO

without further discussion



Signature:_____________________ Name:_________________________ Date:______________

  1. Witness

A witness should sign below if she/he has witnessed the patient’s signature above. Parents or guardians should sign below behalf of patients under the age if legal consent (18 years and above)

Signature:_____________________ Name:_________________________ Date:______________

Relationship to patient: __________________

  1. Confirmation of consent

This section to be completed when the patient admitted for a procedure has sign the form in advance. On behalf of the team treating the patient, I have confirmed with the patient that she has no further questions and wishes the procedure to go ahead.

Signature:_____________________ Name:_________________________ Date:______________

What are Urodynamics?


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What are Urodynamics?

Urodynamics means
the study of pressure and flow in the bladder and the tube through which
you pass urine, the urethra. 
These investigations show what is happening when the bladder is filling
and emptying.  If you’ve been
booked for urodynamic studies you will have been experiencing bladder or
prolapse problems and Dr Aruku has decided that you need to have these
tests done to accurately diagnose and determine the treatment options.

When Do You Need Urodynamics?

Not everyone with bladder problems needs urodynamic studies.
They’re most useful where:


There may be a mixture of symptoms, or uncertain symptoms


Where an operation may be considered and the doctor wants to make sure
it is necessary and will be helpful


Previous treatment has not improved the problem eg physiotherapy or
medication, or


After surgery for bladder or prolapse repairs.

Urinary symptoms like incontinence
(leakage of urine), frequency, dribbling etc. do not accurately tell the
doctor what may be wrong with you.
Urodynamics forms part of a total assessment of your bladder
problem and will help us make an accurate diagnosis so that you get the
right treatment options explained to you.
It may even avoid unnecessary surgery.
Also it guides the surgeon as to what may happen to your bladder
or bowel after surgery.

What is involved?

Please attend with a comfortably full bladder.
When you arrive you’ll be asked to pass urine, in private, into a
toilet or commode.  You’ll be
asked to change into a dressing gown and lie down on a couch.
The doctor will examine your bladder through a fine scope called
a flexible cystoscope.  Then
fine hollow tubes will be passed into your vagina and bladder.
These tubes are attached to a chart recorder that monitors the
pressure in your bladder and abdomen.

The bladder will gradually be filled
with fluid.  You’ll need to
indicate to us what sensations you feel eg. Normal desire to pass urine
and urgency. During the filling of your bladder you will be asked to
cough every so often.  Once the
bladder is full we will get you to stand and cough again and do some
easy exercises like heel bounces.
After this you’ll be asked to pass urine into a special
receptacle, which will record rate of flow of urine.
The staff will usually be able to let you do this in private.
The tubes will then be removed and the procedure is complete.
While the procedure
is taking place, the recording device records a graph of what your
bladder is doing.  Your test
results will be discussed with you by the doctor and treatment options
explained.  The procedure should
take between 20 and 30 minutes. 
Try not to worry –everything will be fully explained to you both before
and during the procedure and every effort will be made to ensure a
minimum of discomfort and maximum privacy

Do I Need to Prepare for the Investigations?

Yes.  Please attend clinic with
a comfortably full bladder.  If
you have a urine infection please contact us so that another appointment
can be made for you.


Most people have no problems after the procedure is performed. You
should drink plenty of fluids for the remainder of the day.
There will be a small amount of irritation caused by catheters,
this should subside in 24-48 hours.
If you do experience burning or stinging when passing urine we
suggest you purchase a packet of ural sachets from your local pharmacy.
If discomfort persists after 48 hours please contact your local doctor
or Dr Aruku’s clinic.



Drugs In The Management of Incontinence

Drugs In The Management of Incontinence

Drugs commonly used for the management of female urinary incontinence can be categorized into the following categories:-

  1. Drugs for overactive Bladder ( OAB)
  2. Drugs for Hypocontractile Bladder
  3. Drugs for Stress Urinary Incontinence
  4. Drugs Acting Outside The Urinary Tract
  1. Detrusor Overactivity ( OAB)

The mainstay of treatment should be behavioural and pelvic floor therapy. When these therapies are ineffective then pharmacological therapy should be added. These pharmacological therapies include:

Anticholinergic Drugs

The drugs of choice are the antimuscarinic drugs. Drugs that are available in Malaysia are:– oxybutynin 2.5-5mg bd/tds (Ditropan ®), Tolteridine 4mg daily ( Detrusitol ®), Fesoteradine (4 and 8 mg), solifenacin 5-10mg daily ( Vesicare ®), Trospium 20mg ( Spasmolyt ®) and  Propantheline Bromide 15md-30mg bd/tds.

This drugs has side effects of parasympathetic blokage like: the complaint of dry mouth which may lead to the undesirable tendency to drink more. It may also cause drowsiness, tachycardia , constipation  and blurred vision. It is therefore contraindicated in patients with acute angle glaucoma and cardiac arrythmia.

In patients with neurogenic detrusor overactivity (detrusor hyper-reflexia) the dosages of these drugs can be increased till the desired inhibition of detrusor contraction is achieved or until intolerable side effects occur. In some cases, oxybutynin can also be instilled directly into the bladder (5mg tablet crushed into 30mls of saline, instilled 3 times per day and retained for 30 minutes each time)

Oxybutynin has the advantage that it can be used in children above the ages of 5 but must be used with caution in the elderly and in those with heart disease. Both drugs are contraindicated in pregnancy, with breast feeding, in patients with glaucoma and myasthenia gravis. Toleradine and fesoteradine newer antimuscarinic agents which as efficacious as oxybutynin and higher tolerability rate among patients.

Other quarternary ammonium compounds with antimuscarinic activities include propantheline (Pro-Banthine ®), emepromium and hyoscyamine (Buscopan®). However these drugs are limited by their unpredictable pharmacokinetics and are not commonly used for detrusor overactivity.

Tricyclic Antidepressants

Tricyclic antidepressants have both anticholinergic and alpha adrenergic effects. These drugs are useful for detrusor overactivity and will at the same time increase the urethral sphincter tone. Their central sedative effect is also an advantage especially in patients who are unduly anxious. Imipramine (25mg od-tds) is usually used. The dose can be increased by 2.5mg/ week until the desired effects are seen or until intolerable side effects occur. Abrupt cessation of the drug must be avoided because of its rebound tendency. side-effects include hepatic dysfunction, mania, cardivascular events.


Flavoxates (Genurin®, Urispas ®) has no appreciable anticholinergic effects but has anti spasmodic activity on the smooth muscles of the urogenital tract. They also have local analgesics effects and are suitable for symptomatic relief of symptoms of irritable bladder syndrome ie cystitis. High doses (400mg tds) can be used for detrusor overactivity. Side effects are few but can cause drowsiness and must be used with caution in patients with glaucoma and obstructive uropathy.

Other Drugs

Other drugs that can be used for detrusor hyperactivity include intravesical capsaisin (substance P antagonist), beta adrenalgic agonists (terbutaline), calcium channel blockers (nifedipine : Adalat®) have been reported with limited success. These drugs are best considered as adjunct to first line therapy.

  1. Detrusor Hypocontractility

Poor detrusor contractility leads to high residual volume and can lead to overflow incontinence. Treatment is directed at improving bladder emptying.

Parasympathomimetic Agents

These are the agents of choice for improving detrusor contractions. Bethanechol chloride (Urecholine®) was the main agent of choice but is not available locally. The alternative is the cholinesterase inhibitor Ubretid ®. This drug can be given with an initial loading dose of 5 to 10mg followed by 5 mg every other day. It should not be used in patients with circulatory insufficiency and bronchial asthma.

  1. Stress Urinary Incontinence and Uretheric Sphincter Incompetence

For the management of Urethreric sphincter incompetency and strees urinary incontinence:  pelvic floor exercises, vaginal devices, injectables and surgery has always been considered the main modality of treatment. However several types of pharmacological agents have been found to be of some benefits. There are alpha adrenalgic receptors on the bladder neck and on the smooth muscle portion of the external urethral spincter and alpha adrenalgic agonists appear to increase the tone of these smooth muscles at the bladder neck. Other pharmacological agents include the Serotonin Norepinephrine Reuptake Inhibitors.

Alpha adrenalgic agonist

Drugs available include epinephrine, pseudoephedrine and phenylpropanolamine. These are commonly found in cough mixtures and nasal decongestants. They should be viewed as adjunct treatment to the other established modalities of treatment for urethric sphincter incompetence.

Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

Duloxetine hydrochloride (Cymbalta ®, Yentreve®) is a drug that primarily targets major depressive disorders and pain related to diabetic peripheral neuropathy. It is now found to be effective in the management of stress urinary incontinence. Using 40mg twice daily, the drug has been proven to reduce incontinence episodes by up to 50% in most individuals. Side effects include nausea, fatigue, dry mouth and insomnia. This drug is not available locally and currently not popular simply because it is expensive and for it’s long term usage. Availability of sling ( SUS) operation with good results further retards it’s usage.

  1. Drugs Acting Outside The Urinary Tract


Topical and oral oestrogens have been noted to exert a trophic effect on the uroepithelium of the urethra and trigone. It is therefore useful in the incontinent women when the urethral mucosal seal in defective. It does not appear to have any effect with incontinence secondary to bladder neck hypermobility. oestraogen ( oestradiol valerate 0.5gm biweekly for 2 months does help in older women with urogenital atrophy (UGA)

Anti-diuretic Hormone (ADH)

Desmopressin (Minirin dDAVP®) is a synthetic vasopressin that increases distal renal tubules reabsorbtion of water. It is effective in the treatment of enuresis where a deficiency of nocturnal ADH is present. It is also useful in the elderly patient with nocturia. It can be taken orally in doses of between 0.2 to 0.4mg at night and at these doses, there will be between 8 to 20 hours of antidiuresis. Its use is contraindicated in those patients with unstable angina and cardiac failure.

Dr Aruku Naidu MD FRCOG CU


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In May
2003 JPA (Jabatan Perkhidmatan Awam), offered the first ever scholarship to
pursue fellowship in Urogynaecology. 
Following few contacts and recommendations, I manage to secure an
urogynaecology and pelvic reconstructive surgery fellowship training
programme with Professor Ajay Rane a well known professor in urogynaecology
from James Cook University (JCU),
, Queensland
is known about JCU and Townsville. My first reaction was to look up in the
world atlas and search the wed site, to see where this place is? Townsville
is the “capital city” of the northern Queensland, with a population of about 150,000 people along
with it twin city Thuringowa, and it make up the largest city in tropical Queensland. Townsville got the name from Sidney businessman Robert Townsville, who sponsored the
establishment of a port in 1864.
excitement turned to horror, especially when I was trying to gain entry into Australia. There are various levels of screening
and protocols to follow before getting a visa. It took almost 4 months to
obtain entry permission. There are also various levels of bureaucracy in
obtaining medical registration with the Queensland medical board.
the long wait, it was time to travel. The flight took 7 plus hours and
further 11/2 hours from Brisbane
as Townsville is situated about 1300kms north of Brisbane. Townsville is quite and peaceful town. The weather
was extremely hot ranging between 32 to 38 degrees. However the weather
became very pleasant between Mac to September (winter months). We (with
family) managed to settle down quickly and the training and posting
commenced smoothly.

to the new environment and system did not take very long as the team in the
urogynaecology department was very helpful. The real work started after the
Christmas and New Year break. The urogynaecology and pelvic reconstructive
department in Townsville is the first subspecialist services in the North Queensland and this unit covers a wide area as up to the Northern Territory. 
Our referrals are mainly from general practitioners and occasionally from
the O & G specialist.
Rane and this team of one senior lecturer (Dr Christopher Barry), 2 fellows
in urogynaecology, and a bladder nurse (Audrey Corstiaans) and other allied
staff is well known not only in Australia
but also in the world of Urogynaecology as a centre of excellence. The
centre carries out various multicentre trials in urogynaecology. It is also
the first centre to invent and publish about Perigee, a device invented to
correct the anterior wall prolepses using transobturator route. I was lucky
to be part of the team when this procedure was introduced and to date
numerous abstracts and papers has been published with regards to this
urogynaecology department is a very busy unit, with almost 95% of their work
concentrated on incontinence and pelvic reconstruction. We were involved in
3 and half days of Clinics, urodynamics & surgery in both the public (Townsville Hospital) as well as the private hospital (Mater’s
Hospital) and Townsville Day surgery Unit. The other days are allocated for
was so much going on at the same time. During my one-year sting, we managed
to organize a North Queensland Urogynae and Pelvic reconstructive surgery
conference. Prof. Bob Schull a well-known pelvic surgeon attended the
conference from Texas, United States. We also carried out nearly 6 trials
or studies. Some of the studies are still on going. We also presented few
papers in the IUGA/ICS conference in Paris.
Apart from that we also published few papers pertaining to urogynaecology. 
was hard initially especially with regards to research as being a clinician
for so long. As time goes by it has become part of work and it was
interesting. There were ample operating opportunities to learn new surgeries
in Uogyanecology and pelvic reconstruction.

aside, the weekends were completely free and we had great time visited the
surrounding areas. Schools are fantastic; children had stress free schooling
with minimal exams and homework. Quality of life was certainly fantastic as
there was ample time to spend with the family. Townsville has few exciting
places to visit; this includes the Billabong Sanctuary, where you can see
and play with Australian wide-life. 
The Reef Headquarters’, the largest reef aquarium world is in Townsville.
The Great Barrier Reef and the Cairns tourist town are only about 350kms north of
Work, research and pleasure as an
urogynaecology fellow in Townsville/JCU quickly elapse and it was time to
set back to the routine and hassle bustle of Malaysian life. The knowledge
and experience gained during this short sting is there to stay in my memory
for a long time.  I wish l could one
day follow the foot steps of my “GURU’ Prof. A Rane, to establish a vibrant
and active Urogynae and pelvic reconstructive unit (Pelvic Health Center) in Malaysia.

Back in Malaysia,
with the help of Dr Mukudan, head of O & G department. I have the opportunity to
start the first Pelvic Health Unit in Ipoh Hospital. The response was tremendous. We can see that there
is so much work in urogynaecology and pelvic reconstruction in Perak alone.
These poor patients were suffering in silence for so long, no where to turn to
or they were provided with substandard advice and treatment. To start

with we introduce the Pelvic Health Concept which basically teaches public how
to take care the pelvic structures.

hospital is the first public hospital to set up the Pelvic Health Unit
(urogynaecology and pelvic reconstructive unit) under the department of
obstetrics and gynaecology. The first line of management is to educate
patients about good bladder habits, such as posture during micturation,
avoidance of bladder irritants, pelvic floor exercises and maintenance of
good general health. Our unit has started the “Beat The Bladder Blues”
campaign to create awareness among care providers and public and how to seek
advice with regards to their bladder or prolapse problem.
We in
the Pelvic Health Unit, Department of O & G. Ipoh Hospital, welcome your
referrals and support. We are contactable at 
05-2085089( urogynaecology Clinic, Ipoh Hospital), 05-2408777(
Sessional clinic Ipoh specialist hospital) and email: