EVEN A YOUNG, DYNAMIC & HIGHLY EDUCATED LADY FACED WRONG DIAGNOSIS OF HER URINE LEAK! Read how I fixed it………
An Educated and IT professional lady in her mid-thirties came to me from Ahmedabad with several complaints about her health. She had arrived in India with a view to seek medical attention for her years long symptoms. She had consulted few specialists but none of them were able to relieve her from her symptoms. She had long term sufferings from what it looked like a mixed incontinence (urine leakage) and had bowel problems, including faecal leakage. She had on and off pain in her lower abdomen and severe symptoms of irritated bladder. She had been consulting a gynaecologist for some years in her country of origin but no relief with the treatment she received. Frustrated with years of suffering ultimately, she decided to consult doctors in India. Hence, she landed in Ahmedabad in Gujarat where her relatives lived. Having no clear-cut guidance as to whom to consult, and from her previous experience she decided to consult Gynaecologist in Ahmedabad who investigated her. After few visits the gynaecologist suggested her to consult a Urologist.
She was taken to one of the well-known urologists in Ahmedabad (was told that he was the topmost) by her relatives. The Urologist put her through several investigations. She was sent to a large corporate hospital for investigations as well as underwent various investigations at the urologist’s private hospital. I was surprised that she was put through cystoscopy under general anaesthesia (telescopic examination of bladder), which in my opinion was unnecessary at that stage. She wasn’t explained about the purpose neither they ever discussed the result with her of that cystoscopy but told her that she had urine leakage (which she already knew about). I would explain this in more details in my next post as to why I called it unnecessary. She had a special study for functional urology called Urodynamic study. I would also explain this in detail in my next post as to what is urodynamic study and why it is done. The Urologist arranged her sonography. She was then put through MRI scan of her backpassage (anal canal) and anal manometry (pressure study of the anal canal), which were totally unnecessary, and they are expensive investigations without any productivity in her case. The Urologist she had consulted involved a general surgeon also for her care.
The urologist and the general surgeon involved in her care formulated their diagnosis and told her that they will do an operation on her. Their interpretation from all those investigations was that she had stress incontinence. Stress incontinence is a leakage of urine on cough, sneeze, laughing or even jumping. It happens due to weak pelvic floor muscles, or weak sphincter (valve at the opening of bladder). They also told her that she would need to undergo a major surgery and that is the only option she has. Urologist explained her the surgery that they would make a big cut on her lower tummy, go in, go under the bladder and lift it up. She was advised a minimum 15 days hospital stay and further rest period. The general surgeon advised her that at the same time he would be performing another surgery on her anal canal. The surgery would involve cutting of the anal canal muscles, stitch it back together to make it strong. No doubt she was scared to death with whatever was explained to her. I had never met her but one of her relative from her back home knew me. Her relative back home located my number and advised her to call me and talk to me for second opinion. She sent me a text message with a reference of her relative and requested whether I would speak to her. In the meantime, her relative from overseas also sent me a message therefore I was aware of her. I spoke to her same evening after my work.
My first consultations are always thorough, and I spend sufficient time with patient to their satisfaction. I believe in detailed history taking, which is THE vital part of any treatment. Making an error in understanding the patient’s medical history, one can end up putting patient through unnecessary treatment and wasting huge costs. I would explain bit by bit what I meant by proper history taking of patient.
Whilst exploring each of her symptom, she told me that she had to pass urine every 15-30 minutes. She also had severe urgency (desire to pass urine which cannot be postpone), and leakage of urine associated with it. She stated that she had terrible nights for many years, and she hadn’t slept well for several years due to leakage, having to wake up many times to pass urine. She had been using pads both day and night which used to be fully soaked. She also had slight leakage of urine with cough and sneeze. She had noticed some blood in her urine few months ago, which was again completely missed by the urologist in Ahmedabad. On pinpointing and asking her what was the most bothersome problem with her? She told me that it was urine urgency, leak of urine associated with urgency, night-time and daytime urine frequency were her most bothersome problems. The leakage during cough was her least of a problem. After exploring her faecal leakage problem and with leading questions I realised that she had leakage of faeces with urgency to pass stools or faeces. The urgency only happened whenever she had loose or watery stools. Whenever she had properly formed stools, she never had leakage of faeces. This type of leak can happen with any normal person when stools are watery and there is urgency due to irritation. I would certainly not advice any surgery for such thing.
Now you may appreciate as to where the urologist and the general surgeon in Ahmedabad were wrong. Both of them failed to take thorough history from her, ask relevant leading questions and pick up important points from the history. It is very important to explore most bothering symptoms. The urologist in Ahmedabad only concentrated on stress incontinence and nothing else. The general surgeon failed to explore as to when exactly she had faecal leakage.
It is absolutely vital to interpret tests carefully and accurately as wrong interpretation could lead to a wrong diagnosis and wrong treatment resulting in patient suffering for lifetime. It is equally important to pay attention to details and read all relevant medical reports carefully. One must not rush in reading reports but pay attention to details. I feel that as a doctor we are paid for our expertise and on the basis of our assessment patients put themselves through a surgery.
The urologist in Ahmedabad completely misinterpreted her urodynamic study (I would explain how, in my next posts). She had ultrasound scan (sonography) in Ahmedabad, where she couldn’t even hold 200 ml of urine in her bladder and started leaking. Her ultrasound scan was misinterpreted and from that wrong diagnosis of her condition was made. It was misinterpreted for stress incontinence when in reality it had happened clearly because of her irritable bladder. All these things led the urologist and general surgeon in Ahmedabad deciding major and completely wrong surgery for her. If she had these surgeries, she could have had lifetime sufferings for no reason and irreversible damage to her urinary and bowel system leading to many more complications for lifetime. The surgery would not have given her relief from her symptoms and her original problem but would have added other problems that she did not have. In fact, this surgery would have made her original problems extremely worst.
She was glad that she made timely decision and came to me for second opinion and further treatment. After assessing her case in detail, I performed an intravesical telescopic surgery without any scars anywhere on her body and with only two day in the hospital. She had complete relief from her problems post-surgery, and she slept peacefully without having to wake up for the first time after many years. I performed an ultrasound scan post-surgically and found that she was able to hold more than 400 ml urine in her bladder without leak and without urgency to pass urine. Her bladder pain completely subsided by day 4 of her surgery. She stopped using pads from second day onwards. She started to enjoy her life and first time after many years she went for shopping without having to look for toilet and rushing to it.
I also investigated her for blood in her urine, and all the investigations came back as normal. It is extremely important to take any episode of blood in urine extremely seriously. No matter single episode, every episode should be investigated thoroughly. I am glad I was able to assess her problems correctly and offer her the right treatment which worked fantastically well. This is the reason why I always give lot of emphasis on thorough history taking, spending sufficient time on first consultation, interpreting investigations correctly. The total cost of surgery in Ahmedabad was going to be well over Rs. 5 lakhs, whereas her complete cost with me was Rs 1.25 lakh in best and topmost room including everything.
I cannot emphasis enough that please do not try to treat someone if you do not have experience or expertise in that area, as if you do try, you can ruin someone’s life! Not every urologist can deal with all urological problems as certain areas require a specific training and experience. Likewise, intravesical procedure that I carry out requires precision which is learnt through thorough training and mastered with experience. Not many urologists are experienced in this area.
One wrong interpretation of an investigation and patient’s life could be ruined, which is extremely concerning for patient or the doctor. On the same note, improper history taking, not spending enough time in patient’s history taking, not paying attention to details on what the patient is trying complaining of and not asking relevant questions about their medical history can put a doctor on wrong tract causing them to make wrong decision. Most of the time this could be disastrous for the patients. We all had been a patient, may be once or may be few times and certainly expect best treatment from any treating doctor. In my medical career I have seen the best doctors and the worst ones too. This is one such example from my practice in India. Hope this example of my own patient would be of some help for people in general including many who had been patients along with the doctors treating their patients.
• Put extra emphasis on your doctor to give you sufficient time in the consultation, specially first consultation.
• Ask your treating doctor their experience in the area which you are consulting them for.
• Ask relevant questions. You are paying the doctors and entitled to answers as it is about your own health.
• Try to understand your body and symptoms, try to assess as to what is your most bothering problem.
• If possible, read about the doctor (their experience and expertise) you are seeing for your major problems.
• Urine leak is not always because of stress incontinence, as if treatment is not given properly for actual problems it not only proves futile but also can cause further problems.