Services in Croydon University Hospital

UROGYNAECOLOGY SERVICES IN CROYDON HEALTHCARE NHS TRUST

The Croydon Integrated Continence Care Service won the 2005 UK Hospital Continence Team of the Year award.

THE TEAM

Lead Consultants:

  • Mr Abdul H Sultan MD FRCOG
  • Miss Ranee Thakar MD FRCOG

Nurse specialists:

  • Miss Wendy Ness
  • Mrs Anne Phillimore
  • Mrs Dahlia Lewis

ROLE OF KEY MEMBERS

Mr Abdul H Sultan is a Consultant Obstetrician and Gynaecologist with a special interest in Urogynaecology and a Reader at St George's Hospital Medical School (SGHMS), London. He is internationally renowned for his pioneering work on anal sphincter trauma during childbirth leading to faecal incontinence. He has obtained a doctoral thesis on this subject, and published extensively. He is currently a committee member of The British Society of Urogynaecology (BSUG) and past Chairman of the Research Committee.

Following his appointment at Croydon University Hospital in 1997, a second urogynaecologist and subspecialist, Ranee Thakar was appointed in 2002 to run the integrated urogynaecological services. Ranee is also a Honorary Senior Lecturer at SGHMS and obtained a MD on pelvic floor dysfunction following hysterectomy. She is the secretary of the International Urogynecological Association. She has previously served as the chair of the meetings subcommittee of the BSUG, the chair of the education committee of the International Urogynecological Association and the Honorary Secretary of BSUG.

In a joint effort they introduced a new concept to multidisciplinary integration and with the help of the team were able to institute the model of care described below. The team presented their experience with this evidence based model in a workshop at The International Continence Society Conference, Paris in August 2004. Abdul and Ranee initiated the first hands-on repair workshop of obstetric anal sphincter injuries in 1999 and these courses have now mushroomed internationally and are held at Croydon University Hospital six times a year. This hospital is the first independent district general hospital to be recognised for Urogynaecology subspecialist training. Abdul and Ranee have written extensively and continue to conduct research, provide training and have written the first comprehensive textbook on perineal trauma.

Anne Phillimore and Dahlia Lewis are urodynamic nurse specialists who also run the triage clinic and are actively involved in pelvic floor education and bladder retraining.

Wendy Ness is the colorectal nurse specialist who co-ordinates the pelvic floor clinics, performs anorectal physiology investigations and is involved in the conservative management of bowel dysfunction eg biofeedback and electrical stimulation. Wendy has obtained a Masters degree in electrical muscle stimulation.

In addition there are 2 part-time nursing staff and 2 full-time community continence advisors who work in an integrated primary and secondary care service. Wendy Naish is the consultant nurse in primary care.

The urogynaecology unit receives tertiary referrals and is an integrated service that adopts a holistic approach to pelvic floor disorders. The following services are provided:

Urogynaecology clinics

Four urogynaecology clinics are held every week (two at Purley Memorial Hospital and two at Mayday University Hospital).

The Triage Clinic

To reduce the patient journey from time of referral to initiation of treatment we introduced a nurse triage clinic in 2003. The nurse specialist assesses and institutes conservative management and only refers selected cases onward to consultant clinics. Within our approved and implemented PCT care pathways, patients come directly to a dedicated nurse-led clinic in the Lancaster Suite rather than the consultant outpatient clinic. This in itself has reduced administration time, outpatient appointments and patient's journey time. All female patients are seen within a month by a nurse specialist who undertakes triage and classifies them within an approved multidisciplinary team framework. If the patient enters the surgical pathway, the nurse specialist performs urodynamics and refers onward to the urogynaecology consultant.

The Pessary Clinic

We have initiated a twice monthly pessary clinic for prolapse and we have access to to wide variety of pessaries. We have also trained the community continence advisors so that they could make domiciliary visits to change pessaries in women with health and mobility restrictions.

The Perineal Clinic

This is a dedicated weekly one-stop postpartum clinic that has facilities for endoanal ultrasound and anorectal physiology tests. It is also open to pregnant women but restricted to postpartum women up to 16 weeks after delivery.

Clinical conditions seen in this clinic include:

  • Urinary incontinence
  • Anal incontinence
  • Genital prolapse
  • Sexual dysfunction
  • Women who sustain third or fourth degree tears

We also see antenatal patients who have sustained a 3rd or 4th degree tear for counselling regarding mode of delivery. This clinic is an exceptional service model that is being adopted by many units internationally.

The Pelvic Floor Clinics

Joint evaluation of complex pelvic floor disorders lead to a more pragmatic approach in treating patients' physical findings and symptoms. Combined surgery, leads to cost savings and a single recuperation period. Our audit revealed that patients rated this service very highly.

These joint clinics (urogynaecologist and colorectal surgeon) are run by 2 teams every fortnight:

Team 1: Mr Abdul Sultan and Mr Muti Abulafi
Team 2: Miss Ranee Thakar and Mr Ian Swift

Bladder retraining and pelvic floor exercises

In contrast to conventional practice we introduced the concept of group therapy classes as opposed to one to one therapy that was still available on request. This has proved very effective because it enabled larger numbers of women to be trained in a shorter space of time without loss of specialist nurse time by non-attenders.

Urodynamic clinic

This is a one stop consultant- led service where women who have complex urogynaecology symptoms are assessed and treated.

Endoanal scan clinic

Patients (both male and female) with anal incontinence, evacuation problems and perianal sepsis are assessed in this clinic.

Surgical procedures

We have four operating lists per week allowing for a range of urogynaecological operations to be performed. Outcomes of all surgical procedures are audited prospectively in accordance with the requirements of the British Society of Urogynaecology.

Relevant Publications

Sultan AH, Thakar R, Fenner D. Perineal and anal sphincter trauma. London: Springer 2007

Kapoor D, Thakar R, Sultan AH. Combined urinary and fecal incontinence Int Urogynaecol J Pelvic Floor Dysfunct. 2005;16:321-8

Thakar R, Chawla S, Scheer I, Barrett G, Sultan AH. Sexual function following pelvic floor surgery. Int J Gynaecol Obstet. 2008;102(2):110-4.

Kapoor D, Sultan AH, Thakar R, Abulafi MA, Swift I, Ness W. Management of complex pelvic floor disorders in a multidisciplinary pelvic floor Clinic. Colorectal Disease 2008;10:118-123

Uchil D, Thakar R, Sultan AH, Seymour J, Addison R. Continence pads: have we got it right? Int Urogynecol J & Pelvic Floor Dysfunct. 2006;17(3):234-8.

Fernando R, Thakar R, Sultan AH, Shah S, Jones P. Are vaginal pessaries effective in controlling symptoms associated with pelvic organ prolapse? Obstet Gynaecol 2006;108(1):93-9.

Fernando RJ, Sultan AH, Thakar R, Jeyanthan K. Management of the neglected vaginal ring pessary. International Urogynaecology Journal and Pelvic floor dysfunction 2007;18:117- 119

Oliver R, Thakar R, Sultan AH, Phillimore A. Urogynecology triage clinic: model of healthcare delivery. Int Urogynecol J Pelvic Floor Dysfunct. 2009 in press