Publications: Approach to Female Urology - Reflecting Asian Views
Chapter 1: Development of Female Urology In Asia And The Importance Of Pelvic Floor Centres To Enhance This New Specialty
By Professor Peter Lim Huat Chye, Singapore

EXECUTIVE SUMMARY
Female urology is a relatively new discipline in the Asia-Pacific region. The development of this field is beset by lack of urodynamics equipment and an archaic mindset that restricts cooperative ventures between urologists and gynecologists. More importantly, the suppliers of medical care in this developing part of the world is more concerned with the main pillars of internal medicine, general surgery and routine obstetrics and gynecology that can deliver basic medical care. Subspecialties are just beginning to make their impact and female urology is considered “Johnny come lately”!

Recent epidemiologic surveys done on the prevalence of incontinence in this region only demonstrate clearly the volume of work that springs from the Asia Pacific rim. The crying need for expertise is being hampered by “turf wars” between specialists and a “tunnel view” perspective of what constitutes female urology and the chosen practitioners to tend to these patients.

Nonetheless relatively recent initiatives from the Asian Continence Societies and the Asian Society for Female Urology in particular, banded urologists and gynecologists together within a common crusade to develop the specialty of female urology/pelvic surgery. Attempts are underway to formulate a common syllabus for the training of this new group and several Asian centers are already offering training in Singapore, Taiwan and India to suitable Asian candidates who must first be certified in their own countries as trained urologists or gynecologists as the entry point.

The Asian Society for Female Urology was founded to unite one and all under one common banner and produce guidelines and create a viable training program for the new entrant into the field of female urology/pelvic surgery. The final push of the Society is to have one common exit Board Certification for the region.

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Chapter 2: Anatomy of The Lower Urinary Tract
By Dr Ho Siew Hong, Singapore

EXECUTIVE SUMMARY
The lower urinary tract comprises of the urinary bladder, urethra and the sphincteric unit. It has two main functions, firstly, being a passive reservoir for temporary storage of urine and secondly, an active function of eliminating urine from the reservoir at an appropriate time.

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Chapter 3: Physiology of Micturition
By Associate Professor Marie Carmela Lapitan, Philippines

EXECUTIVE SUMMARY
The act of micturition, i.e. the act of eliminating urine, is a special process of the human body which is both under voluntary and autonomic control. Its physiology is a complex synthesis of the unique anatomic and histologic properties of the lower urinary tract organs under precise neurologic control and coordination to allow storage and periodic elimination of urine. There are two phases of the micturition cycle: (1) the filling or storage phase, and (2) the voiding phase.

The key to normal micturition is the reciprocal relationship between the bladder and the outlet (urethra and pelvic floor) brought about by a system of on-off switches among certain areas of the nervous system including the cortical center, rostral pons, suprasacral spinal cord, sacral spinal cord, hypogastric nerves, pelvic nerves and the pudendal nerves. These centers are responsible for ensuring the proper sequence of events that normally takes place during the filling and voiding phases of micturition.

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Chapter 4: Evaluation of Incontinence and Pelvic Floor
By Associate Professor Suvit Bunyavejchevin, Thailand and Associate Professor Marie Carmela Lapitan, Philippines

EXECUTIVE SUMMARY
The foundation for the evaluation of incontinence and the pelvic floor lies on taking a proper history and on conducting a comprehensive physical examination. The goals of the initial evaluation are to identify the nature of the incontinence, the degree to which it interferes with the lifestyle and activities, the objective demonstration of incontinence, pelvic floor dysfunction and/or pelvic organ prolapse, and the identification of neurologic, gynecologic and other medical conditions that predisposes to incontinence and pelvic floor dysfunction.

Clinicians must be prepared to elicit a complete history directly from the patient, which should include questions investigating the urologic, obstetric, gynecologic, neurologic and other medical aspects of the patient’s condition. The physical examination of patients with incontinence and pelvic floor disorders should include a general assessment, a demonstration of the leakage through provocative stress test, a neurological examination, a gynecologic examination wherein prolapse may be graded as necessary, and an assessment of the pelvic floor muscle strength.

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Chapter 5: Investigative Tools In Incontinence and Pelvic Floor Dysfunction
By Dr Roy Ng Kwok Weng, Singapore

EXECUTIVE SUMMARY
The cornerstones in the investigation for urinary incontinence and pelvic floor dysfunction in the female are the clinical history and physical examination. However, as the bladder is often labeled as an “unreliable witness”, many authors and clinicians advocate the use of ancillary tests to arrive at a more accurate diagnosis for patients complaining from incontinence and other lower urinary tract symptoms.

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Chapter 6: Etiology of Urinary Incontinence
By Dr Vasan Satya Srini, India

EXECUTIVE SUMMARY
Urinary incontinence is a highly prevalent condition which influences the social, occupational, domestic, physical, sexual and psychological functioning in individuals. Though age-related changes are common in the lower urinary tract, incontinence is prevalent due to psychological, physiological, pharmacological or pathological factors. Despite the vast majority of causes the three common presentation types of persistent urinary incontinence are stress, urge and overflow and the pathophysiology is incompletely understood and deceptively complex.

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Chapter 7: The Overactive Bladder – Current Concepts and Pharmacology
By Dr Ho Kwan-Lun, Hong Kong and Dr Tam Po-Chor, Hong Kong

EXECUTIVE SUMMARY
Overactive bladder is a common condition in Asia and worldwide. It has a significant impact on patients’ quality of life. Unfortunately, this condition is under-reported and definitely undertreated in Asian countries. Pathogenesis of overactive bladder is complex and likely multi-factorial. Novel treatments are being developed but their efficacies have to be compared with traditional antimuscarinics in well-designed clinical trials.

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Chapter 8: The Female Neurogenic Bladder: Challenges, Pitfalls And Management
By Dr Adela Tow Peh-Er, Singapore and Dr Kong Keng He, Singapore

EXECUTIVE SUMMARY
Management of the female neurogenic bladder requires accurate diagnosis, evaluation and classification and choosing an acceptable mode of voiding. Urodynamic examination is essential for accurate diagnosis and classification. Achieving the goals of upper tract preservation with bladder filling and storage at low pressure, continence and quality of life remain a challenge for most individuals.

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Chapter 9: Hypotonic Bladder – Updates
By Dr David Consigliere, Singapore and Assistant Professor Edmund Chiong, Singapore

EXECUTIVE SUMMARY
Hypotonic bladder is a poorly defined entity. Impaired detrusor contractility better describes the underactive/acontractile detrusor as defined by ICS terminology. IDC may be caused by disorders affecting the detrusor muscle or its nerve supply. Pathophysiology probably involves biologic ageing, neuropharmacological, hormonal and vascular factors. The gold standard of treatment is clean intermittent catherisation but alternative treatment modalities can be divided into interventions at the bladder innervation, detrusor muscle or the bladder outlet. Further studies are required to establish their role in clinical management of this challenging condition.

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Chapter 10: Urinary Incontinence in Children
By Dr David T Bolong, Philippines

EXECUTIVE SUMMARY
Involuntary voiding is normal among the very young. Daytime control happens at around three years but nighttime wetting still occurs. Day and night dryness comes around 41⁄2 years of age and any involuntary loss of urine beyond this age is called enuresis. When incontinence occurs during daytime it is called diurnal enuresis, if occurs at night it is called nocturnal enuresis. The prevalence of incontinence is the same among Asians and Westerners. Enuresis decreases with age. Most will ultimately become dry, however, 2-5% will persist till adulthood. The classic work of Forsythe and Redmond showed that the spontaneous cure rate was 14% annually between the ages of five and nine years and 16% between ages 10-19 years; 3% were still wetting after 20 years. There are usually more boys than girls.

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Chapter 11: Incontinence in Geriatric Population
By Dr Edmund Man Fuk Leung, Hong Kong

EXECUTIVE SUMMARY
Urinary incontinence is a common symptom amongst older people and is one of the main causes of institutionalisation for older people. Urinary incontinence also affects the quality of life of older people and sometimes hinders the social interaction of its sufferers. Often the causes of urinary incontinence are not well understood and it has been attributed by many as part of ageing. Through better understanding the ageing changes in urinary tract, healthcare professionals will be better aware of the abnormality causing urinary incontinence in older people. Many older people suffering from urinary incontinence are due to transient causes like medical conditions, urinary infections; environmental causes which are amenable to treatment and correction. For those older people who suffered from organic causes of urinary incontinence could be managed by physical measures, environmental correction, rehabilitation, medical treatment, surgical treatment and behavioural management.

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Chapter 12: The Management of Male Incontinence
By Dr Siow Woei Yun, Singapore and Dr Michael Wong Yuet Chen, Singapore

EXECUTIVE SUMMARY
  1. Male urinary incontinence is less common than female urinary incontinence but no less distressing to the patient;

  2. Causes include stress, urge, mixed, transient and overflow incontinence. Specific causes include post micturation dribble and post prostatectomy incontinence;

  3. The artificial urinary sphincter is by far the most invasive though most effective treatment option for male urinary incontinence.
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Chapter 13: Genitourinary Fistulae – With Reference To Situation in Pakistan
By Professor Javed H Rizvi, Pakistan and Associate Professor Tahira Naru, Pakistan

EXECUTIVE SUMMARY
One of the hazards of child bearing and pelvic surgery is injury to the urinary tract. Fistulous communication between the genital tract and adjacent organs is a social calamity. It is among the most distressing, demoralising and degrading conditions from which women suffer. The etiology of genitourinary fistulae is varied but the overwhelming proportions are complications of neglected obstructed labor. This is of paramount importance in the developing countries. The gynecologists, therefore, must familiarise themselves with identification and treatment of such mishaps, if and when they occur. Help and opinion of a urological colleague is invaluable, but this is not always available to many surgeons working in developing countries.

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Chapter 14: Urogenital Fistulae in Females
By Dr Bakhtawar K Dastur, India

EXECUTIVE SUMMARY
Genitourinary fistulae are abnormal communications between the urinary and genital tracts leading to a constant uncontrolled leakage of urine. In 1949 Mahfouz reported finding fistula between the bladder and the vagina in an Egyptian mummy; some 4,000 years old. There is also mention of urogenital fistula in the writings of the Hindu medicine around 600 BC (McKay 1901). Obstetric vesicovaginal fistula (VVF) remains a significant cause of female urinary incontinence worldwide. Approximately two million women suffer from this condition, most of whom are in Africa. Expert midwifery services are still lacking in many regions of the tropics including India. In India, the majority of women living in the villages undergo labour for days attended only by the childbirth attendants (dais). Motherhood starts at a very young age, sometimes soon after puberty. This has resulted in many suffering from obstructed labour, because of cephalopelvic disproportion, thus resulting in genito-urinary fistula. It has been estimated that obstetric bladder injury occurs in 0.1 per 1,000 deliveries and 1.4 per 1,000 caesarian sections. Urethral injury is less common with estimated incidence of 0.03 per 1,000 deliveries and 0.27 per 1,000 caesarean sections.

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Chapter 15: Transvaginal Approach in Vesicovaginal Fistula
By Dr H Junizaf, Indonesia

EXECUTIVE SUMMARY
The problems related to vesicovaginal fistula has long been a subject of discussion, and they are encountered not only in the developing countries, but also in the developed countries. Vesicovaginal fistula caused by obstetric trauma and gynecologic surgery poses a serious problem for patients because they do not only create discomfort but also give rise to quite disturbing and embarrassing psychosocial problems. In the developed countries, the primary cause of vesicovaginal fistula is a complication resulting from gynecologic surgery, radiation therapy or tumor. In the developing world, the primary cause of vesicovaginal fistula is obstetric trauma, such as prolonged labor, forceps extraction and vacuum extraction.
Chapter 16: Biofeedback and Behavioural Approach to Urinary Incontinence
By Professor Masood Ahmed Sheikh, Paskistan

EXECUTIVE SUMMARY
Urge incontinence – the involuntary loss of large volumes of urine, is a very distressing symptom especially in women with overactive bladder. Behavioural therapy teaches patients to control the physiological response of the bladder and pelvic muscles which mediate continence. The rationale for the use of bladder training is that it inhibits involuntary contractions of the bladder. Biofeedback is a useful adjunct to improve voluntary control. Timed bladder emptying, Kegel exercises, anorectal and verbal feedback along with urge strategies are used for the benefit of the patient. Both these methods are used to treat disorders of urine release and storage.

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Chapter 17: Management of Sexual and Psychosocial Problems in Urinary Incontinence
By Dr William Han How Chuan, Singapore

EXECUTIVE SUMMARY
Urinary incontinence affects the quality of life of sufferers. The sexual and psychosocial problems of incontinent patients are often under reported and inadequately managed. Many patients have been suffering in silence! When treating incontinent patients, clinicians should also bear in mind associated sexual and psychosocial problems and manage them so as to improve the patients’ quality of life.

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Chapter 18: Current Surgical Approach to Stress Urinary Incontinence in Women
By Dr Siow Woei Yun, Singapore and Dr Michael Wong Yuet Chen, Singapore

EXECUTIVE SUMMARY
  1. Female urinary incontinence is highly prevalent worldwide;

  2. Currently, only a small proportion of sufferers seeks help;

  3. Non surgical modalities encompass pelvic floor exercises, bladder retraining, vaginal cones, electrical stimulation, pharmacotherapy and absorbent devices;

  4. Surgical treatment options include periurethral bulking agents, colposuspension, sling operations and artificial urinary sphincter.
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Chapter 19: Colposuspension in SUI
By Dr Cecilia Willy Cheon, Hong Kong

EXECUTIVE SUMMARY
Colposuspension is still considered to be the gold standard for treating stress urinary incontinence because of its high long term success rate. Laparoscopic colposuspension can be regarded as a viable alternative for the conventional open method. The cost effectiveness and long term success rate is still controversial. With the emergence of tension-free vaginal tape, the usefulness of colposuspension will face new challenges.


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Chapter 20: The Technical Aspects of Tension-free Vaginal Tape – TVT
By Associate Professor Alex Cheng Wang, Taiwan

EXECUTIVE SUMMARY
Tension-free sub- mid-urethral implantation of synthetic mesh (TVT) was found to be safe, effective and minimally invasive for women with urinary stress incontinence. Nevertheless, these advantages need to be balanced with the risk of incurred complications such as lower urinary tract perforation, sling erosion, major vascular and bowel injuries, etc. However, these complications are preventable once physicians obey the principles of triad, i.e. good anesthesia, safe trocar insertion (including painstaking urethrocystoscopy) and correct tape adjustment. The author shares his experience with 600 cases of TVT procedure with a 0.8% bladder perforation rate, 90% objective success rate and no major complications.

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Chapter 21: Tension-free Vaginal Tape in the Management of Genuine Stress Incontinence in Women – The Indian Experience
By Associate Professor N Rajameshwari, India

EXECUTIVE SUMMARY
Goebell described the use of pubovaginal slings for the treatment of GSI almost a century ago. The concept of TVT evolved after Petros and Ulmstein published their integral theory on female SUI. The integral theory proposed that the anterior vaginal wall plays a central role in balancing pelvic floor support and the pubourethral ligaments are pivotal in anchoring the anterior vaginal wall. Ulmstein et al in Sweden first described the TVT procedure using a knitted prolene mesh to correct the defect in pubovaginal ligament support. The TVT is done as an ambulatory procedure under local anesthesia. Stanton and Atherton suggested that exertion kinked the urethra at the level of the tape (midurethral level) and urethral hypermobility is however not altered.

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Chapter 22: Pubovaginal Sling: Past, Present And Future
By Professor Wachira Kochakarn, Thailand

EXECUTIVE SUMMARY
Pubovaginal sling is an effective surgical treatment for stress urinary incontinence from both intrinsic sphincter deficiency (ISD) and hypermobility of urethra. Sling materials that can be used are rectus sheath, fascia lata, vaginal wall, cadaveric sheath and synthetic materials. Long term results of this procedure have been reported as more than 80% success rate. The common complications are urinary retention and erosion if synthetic materials are chosen. However, this procedure shows more invasive than up-date minimal invasive surgery and needs longer period to recover. The author reported his experience of 100 cases who underwent pubovaginal sling with 94% success rate over 12 months and with minimal complications. In conclusion, pubovaginal sling shows the effectiveness and high success rate in the long term results. It can be indicated for stress incontinence especially in cases of ISD and after failure of other minimally invasive surgery.

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Chapter 23: Transpubic Approach for Female Urethral Reconstruction
By Professor K Sasidharan, India and Associate Professor Arun Chawla, India and Associate Professor Kumaresan Natarajan, India

EXECUTIVE SUMMARY
Transpubic approach to male urethra for selected complex reconstructive surgery is reckoned as a validated surgical access. Its use however, is seldom exploited for female urethral reconstruction. We believe that in suitably selected cases this approach provides an equally excellent and strategic exposure of the retropubic territory in female and aids urethral reconstruction. We have found the transpubic access exceedingly useful in situations where the trigone provides the urethral plate for urethral reconstruction. Anomalies of the external urethral meatus and female hypospadias with total incontinence exemplify such indication. It is singularly devoid of short and long term complications and does not adversely impact the pelvic visceral supports and stability.

Chapter 24: Biomaterials and Injectables
By Dr Pearllyn Quek Leng Choo, Singapore

EXECUTIVE SUMMARY
The relative simplicity and minimal nature of periurethral bulking is offset by its less than durable efficacy in the long term. The search for more permanent bulking agents continues. However, in these days of minimally invasive slings, the role of injectables in the management of stress incontinence is being questioned. Nevertheless, it may yet have a place for SUI due predominantly to sphincter incompetence in an unfit patient or those with failed previous anti-incontinence procedures despite good repositioning of the bladder neck.

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Chapter 25: Neuromodulation in Urinary Incontinence
By Professor Jeong Gu Lee, Korea

EXECUTIVE SUMMARY
A group of patients with overactive bladder symptoms will prove to be refractory to the pharmacological or behavioural therapeutic methods. These patients should have further evaluation with urodynamic testing and cystoscopy to define the nature of the lower urinary tract dysfunction and to rule out other causes for the refractory overactive bladder symptoms. For the patients who truly have refractory detrusor overactivity, the options are neuromodulations or surgical reconstructions. Of the several techniques of the neuromodulations, sacral neuromdulations seem to be the most reliable ways of managing this condition with almost 75% of the patients experiencing symptom relief.

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Chapter 26: Augmentation Enterocystoplasty for Neuropathic Patients
By Professor Hemant R Pathak, India

EXECUTIVE SUMMARY
Bladder augmentation is a commonly performed operation in most urology centres. The introduction of CIC by Lapides has revolutionised our approach to the management of bladder emptying. Abnormal storage function due to reduced detrusor compliance, hyperactivity and reduced functional capacity are the main reasons for augmentation in neuropathic bladder. It is undertaken after failure of CIC and medical management. Technique and choice of bowel  segment may vary and many patients require additional surgery viz., outlet enhancement, catheterisable stoma, urethral reimplantation, etc. to achieve success. Complications include infection, stones, voiding inefficiency, bowel obstruction, perforation and metabolic abnormalities. Despite all these problems, augmentation cystoplasty is a successful procedure with high degree
of patient satisfaction.

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Chapter 27: Post Prostatectomy Incontinence
By Dr Rudi Yuwana, Indonesia

EXECUTIVE SUMMARY
Prostatic surgery belongs to the category of one of the most frequent operations performed in the elderly male. Although preoperative investigations have improved and surgical techniques have been refined and postoperative control of complications been intensified, there is still a number of patients suffering from prostatectomy incontinence. The fact calls for continuos efforts to avoid this problem and in finding suitable solutions for the treatment of prostatectomy incontinence.

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Chapter 28: Management of Faecal Incontinence – The Principles
By Dr Wong Soong Kuan, Singapore

EXECUTIVE SUMMARY
Faecal incontinence is defined as the ability to defer defecation to a chosen time and place. This is currently a problem that is underestimated and misunderstood. It has been reported that fewer than 50% of patients with faecal incontinence report the symptom to their clinician. The clinical evaluation of the incontinent patient is critically important as with appropriate and relevant diagnostic tests, accurate diagnosis can result in effective treatment. This guide has the two-fold aim of providing guidelines for the practising clinician and a synopsis of treatment modalities currently available.

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Chapter 29: Nursing Management of Urinary Incontinence
By Clinical Instructor Chia Hwee Huang, Singapore

EXECUTIVE SUMMARY
Nursing management of urinary incontinence not only involve inappropriate preventive measures in keeping the patient clean and comfortable, but also active intervention in the promotion of continence.

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Chapter 30: Appliances, Aids and Catheters
By Senior Staff Nurse Baty Ng Bee Lian, Singapore

EXECUTIVE SUMMARY
Many products have been specifically developed to enable incontinent people to achieve social continence, promote personal dignity and restore confidence to the user.

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Chapter 31: Practical Care: Intermittent Catheterisation
By Senior Nursing Officer King Foong Meng, Singapore

EXECUTIVE SUMMARY
People have been using intermittent catheterisation – the passing of a single channel, hollow tube into the bladder, intermittently via the urethral to drain urine-for many centuries. Intermittent self catheterisation reduces the risk of urinary tract infection and can greatly improve the quality of life for many patients experiencing problems with voiding. If patients are unable to perform self catheterisation, a relative or caregiver can be taught. Intermittent catheters are made from latex, plastic, stainless steel and silver. Uncoated plastic catheters can be reused for up to one week in the home setting.

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Chapter 32: Bladder Re-Education
By Nurse Clinician Tay Lee Hua, Singapore

EXECUTIVE SUMMARY
Bladder re-education is a method of training the patient to take control over his/her bladder by behavioural modification. It can be used alone by itself or in conjunction with other therapies, e.g. drug or pelvic floor exercise.

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Chapter 33: Pelvic Floor Management
By Senior Physiotherapist Sonya Gill Kaur, Singapore

EXECUTIVE SUMMARY
The pelvic floor muscles are striated muscles of support which come under voluntary control. Thus, they can be retrained using ordinary therapeutic techniques such as Kegel exercises, electrotherapy and biofeedback.

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Chapter 34: Stoma Management
By Nurse Clinician Tay Ai Choo, Singapore

EXECUTIVE SUMMARY
An ostomy is a surgical opening made for the elimination of body waste. The opening is called a stoma. A stoma is not a disease. It is a bypass to maintain normal excretory function without a rectum, diseased colon or urinary bladder. A colostomy is an artificial opening in the large intestine brought out to the surface of the abdomen. It is created for congenital abnormality, injury, cancer or other diseases. An ileostomy is created from a part of the small intestine called the ileum. It is usually done when the large intestine (colon) is diseased and needs to be removed completely. A urostomy is constructed to replace the function of the urinary bladder, which may have been removed due to cancer or may be diseased due to congenital abnormality or spinal injury. It is important to know which type of stoma your patient has because day to day management is different for each. Only specific information pertaining to urostomy will be discussed in this chapter.

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Chapter 35: Running the Continence Clinic
By Nurse Clinician Heng Lee Choo, Singapore


EXECUTIVE SUMMARY
Incontinence is a treatable condition and nurses are part of the team in providing cost effective and quality care. In Singapore, we have developed an integrated continence services managed by a specialist nurse in continence clinic.

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Chapter 36: Toilets, Incontinence And Other Toilet Related Diseases
By Professor Peter Lim Huat Chye, Singapore

EXECUTIVE SUMMARY
Incontinence can be due to many causes. This chapter will trace the many reasons why men and women cannot control their bladders. It will emphasise the contribution made by the quality or lack thereof of toilets that are found in our individual countries that impact upon how we can reduce infections of the urinary system; encourage proper and effective use of toilets and trace the innovations that common folks have devised that make for quicker access to toilets at home and at work that have saved many a person from that inevitable “leak” or “accident”. It will further demonstrate the many ideas that technology and forethought that currently contributes to better quality, either simple, low-tech or highly sophisticated technological models that will make life good for able-bodied as well as the handicapped to control their bladders and lead better lives.

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Chapter 37: Overview of Continence Organisations in Asia
By Rani Vadiveloo, Singapore

EXECUTIVE SUMMARY
The International Continence Society (ICS) in setting up a Continence Promotion Committee (CPC) in 1993, recognised a broader responsibility than its former role of just being a forum for scientific research. This led to an impetus  accelerating the formation of self groupings and  organisations in Asia which lobbied for Continence Care Services to be established and efforts to promote continence in the community.

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