Uro-Gynaecology (UG): Sub-speciality of gynaecology dealing with benign disorders of the lower urinary and genital tract, mainly urinary incontinence and genital prolapse.

1. Uro-Gynaecology From
Cambridge to UAE?
May 2018 UAE

2. Are there any existing Abu Dhabi
Uro-Gynaecology Services?
Detailed Google search:
22 centres in Abu Dhabi cited as providing
treatment for incontinence and prolapse
On analysis of the cited specialists and services:
• There is no dedicated Uro-Gynaecology and Female
Pelvic Floor Disorders unit in Abu Dhabi
• There are no subspecialist accredited
Urogynaecology consultants

3. What is a Uro-Gynaecologist?
Uro-Gynaecology (UG): Sub-speciality of gynaecology dealing
with benign disorders of the lower urinary and genital tract,
mainly urinary incontinence and genital prolapse.
A Uro-Gynaecologist:
1. Has evidence of training in a specialist unit, providing the full range of investigations and
treatments required for practice as a subspecialist.
2. Has advanced urodynamics experience (e.g. Special Skills Training).
3. Provides >2 urodynamic sessions per month (in person or a supervisory capacity).
4. Provides 3 general clinical sessions in UG per week.
5. Provides a minimum of 1 specialist combined UG clinic per month as part of an MDT
(e.g. Childbirth trauma, combined colorectal, combined functional and neuro-urology).
6. Undertakes at 1-2 major UG procedures associated with pelvic floor dysfunction
(i.e. incontinence and prolapse) per week per year.
7. Audits their practice (e.g. BSUG surgical audit).
8. Undertakes annual appraisal demonstrating a proportion of CME in UG.

4. Career background
From
02/2017
Locum Consultant Gynaecologist Urogynaecology, Paediatric Adolescent Gynaecology and Reproductive
Medicine Cambridge University Teaching Hospital(s) NHS Foundation Trust (CUHFT), Cambridge UK.
2003-2016 Consultant Urogynaecologist, Reconstructive Pelvic Surgeon, Perineal/Childbirth Injury, Paediatric Adolescent
Gynaecology, St. George’s University Hospitals NHS Foundation Trust and St George’s University of London.
2005-2015 Preceptor for RCOG/BritSPAG and RCOG/BSUG Advanced Training Skills Modules (ATSMs).
2003-2016
Honorary Senior Lecturer for Obstetrics and Gynaecology, at SGUL, London, UK.
2003-2012 Uro-Gynaecology subspecialty RCOG Training Program Director based at St George’s Hospital, London, UK.
2002-2003 Completed a subspecialty training at SGUH FT and accreditation for Urogynaecology by the RCOG.
1999-2002 Subspecialty training programme completed. Accreditated with Diploma Urogynaecology awarded by
RANZCOG.
2000-2001 Consultant Gynaecologist, Mercy Hospital & Austin Repatriation Medical Centre Victoria, Australia.
Senior Lecturer University of Melbourne Australia
2000 Doctorate of Medicine (MD) for research awarded by the National University of Ireland.
2000 Diploma Advanced Ultrasound (DipUS), RCOG and Royal College of Radiology (RCR), London, UK.
1997-1999 Senior Lecturer Obstetrics & Gynaecology, Cambridge University, Cambridge, UK.
1996 Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG).
1995 Lecturer Obstetrics & Gynaecology, University College Dublin, National Maternity Hospital, Ireland.
Michelle Checinska-Fynes MB BAO BCH (Hons) MD (Research) MRCOG DU DipUS
Dual subspecialist accredited Uro-Gynaecologist
RANZCOG 2002 and RCOG 2003
RCOG Subspeciality Training Programme Director 2003-12
Service Lead for Uro-Gynaecology 2003-2012
Specialist Paediatric Adolescent Gynaecology
14.5 years experience NHS Consultant Uro-Gynaecologist

5. What should a subspecialist Urogynaecology and
Pelvic Floor Disorders Unit comprise?
Core medical team
• Lead Uro-Gynaecologist
• Clinical Nurse specialist
• Physiotherapist
• Perineal Care Midwife
• Link to colorectal services
• Link to neurology services
• Link to pain anaesthetist
Clinical space and equipment
• Dedicated clinical space
• Urodynamics equipment
• Ultrasound (TVUS Endo-anal) and Bladder scanner
• Outpatient cystoscopy (for diagnostics, Botox, bulking)
• Anal manometry and basic EMG
• Capacity to undertake minor outpatient surgical procedures
• Capacity to undertake outpatient local pain blocks
• IT access and medical physics support

6. What spectrum of conditions does a subspecialist
Uro-Gynaecology and Pelvic Floor Disorders Unit treat?
Sexual dysfunction (e.g. dyspareunia, vaginismus, loss of libido)
Childbirth injury (e.g. Obstetric Anal Sphincter Injury [OASI], fistula)
Bowel disorders
• Incontinence
• Defecatory difficulty
These problems are effectively treated within specialist clinics
provided by the Urogynaecology & Pelvic Floor Disorders Team
Females of all ages with Urinary Incontinence
and Urogenital Prolapse
Other Lower Urinary Tract Disorders
• Recurrent urinary infection
• Overactive bladder
• Painful bladder disorders
• Difficulty with bladder emptying
• Urogenital fistula
• Urethral diverticula
Complications POP and UI surgery (e.g. mesh)
Urogenital pain disorders

7. Why does Abu Dhabi need a Subspecialist Uro-Gynaecology and
Pelvic Floors Disorders unit?
Urinary Incontinence (UI) affects
10-20% women aged 15-64 years
30-40% >60 years
50% in long-term care facilities
1 in 8 women will have surgery for urinary incontinence
Pelvic Organ Prolapse (POP) affects
50% women >50 years of age
30-50% lifetime prevalence
10% lifetime risk surgery
13% 2nd operation within 5 years
30% have further surgery for POP/SUI in their lifetime
PUBLISHED FACT: Subspecialist Uro-Gynaecology and
Pelvic Floor Disorders centres with accredited consultant
providers have better outcomes, fewer complications and
can offer a wider variety of treatments.
‘Effective care requires a broad and detailed understanding of normal and
abnormal bladder bowel and pelvic floor muscle function in order to
provide the right care package (e.g. surgery), at the right time, for the
right patient, by the right doctor. UAE websites typically offer the
procedure (e,g, we undertake TVT) rather than the package of care.‘

8. What would an
enhanced subspecialist
Uro-Gynaecology and
Pelvic Floor Disorders
unit look like?

9. Corniche Hospital
Uro-Gynaecology and
Female Pelvic Floor Disorders Unit
Assessment
Diagnosis and Treatment
Hub
Uro-Gynaecology and Pelvic Floor
Disorders Service
Nurse Led Women’s Health Triage
for the Pelvic Floor Diagnostics Unit
A&E or
self referrals
Referrals from
physiotherapy on agreed
pathways
In-house referrals
along agreed pathways
Health Clinic Referrals
Family Doctor (GP)
Referrals from other
maternity services
Referrals from other
SEHA and non-SEHA
Hospitals
Postnatal referrals from the
ward or other maternity
hospital services
Referrals from antental
or booking clinics
Non-childbirth related:
Adolescent
Premenopausal
Postmenopausal
Elderly care medicine
Childbirth related antepartum
or first six months postpartum
Adolescent or
paediatric urology
referrals or transition
cases referrals
First line conservative therapy for 3-6 months minimal investigations
formal assessment of outcome
Persistent symptoms and or request for
further therapy by patient that is deemed
appropriate and in line with care pathways
Secondary assessment clinical evaluation and or
diagnostics as indicated by the appropriate care
pathways discussion with patient
Neuro-Urology and
Uro-Gynaecology
Disorders
Specialist Combined
MDT clinic
Uro-Gynaecology
and Colorectal
Disorders Specialist
Combined MDT clinic
General
Uro-Gynaecology
Clinics
Complex Urology &
Uro-Gynaecology
Disorders
Specialist Combined
MDT clinic
Symptoms resolved or
improved and or patient
satisfied
Discharge to GP
Patient joins
appropriate ongoing
pathway
Paediatric and
Adolescent Uro-
Gynaecology
M Fynes 04/2018
Complex cases or red flags as indicated on the First line triage
flow chart and care pathway
Perineal
Childbirth Injury
Clinic
Discussion or
MDT sign-off
Referral to appropriate
specialist clinic
Referrals screened triaged to the correct care pathway and clinic;
General Uro-Gynaecology (primary incontinence and prolapse),
Childbirth Injury (OASI), Sexual Difficulties,
Complex or combined (e.g. bowel incontinence, recurrent prolapse, mesh complication)
Vision for a UAE based subspecialist service

10. Expanding the
UAE service
referral base?

11. Care Pathways:
Providing evidence based
care for all Uro-Gynaecology
and Pelvic Floor Disorders

12. The role of
care pathways
Care pathway:
First-line management of Urinary Incontinence
Based on NICE Guidelines for management of urinary
incontinence in women 2006.
MMF pathway V2 April 2018

13. The role of
care pathways
1. I have drafted 15 evidenced based care pathways
for the most common conditions referred to the Uro-
Gynaecology and Pelvic Floor Disorders.
2. These optimize success rates and minimize
morbidity whilst promoting patient safety.
3. The pathways may be incorporated into the IT
platform (e.g. EPIC) to facilitate compliance/audit.
Care pathway: Management
of Recurrent Stress Urinary
Incontinence (SUI)

14. Robust Governance:
1. Clinical: Providing evidence based
high quality patient centred care
pathways with measurable and
recorded outcomes (including QoL)
2. Finance
3. Education and Training

15. Corniche Hospital
Uro-Gynaecology and Female Pelvic Floor Disorders Unit
Clinical Management, Business Structure, Governance and Quality Assurance
Financial Governance
1. Regular scheduled meetings with clinical, operational and administrative
managers, medical and clinical support staff.
2. Regular meetings including; governance, financial and service planning.
3. Service utilization audits and exploration options to improve business capture.
4. Mandatory attendance at >70% required per annum.
Financial Best Practice Care Pathway Costings and Service User Fees
determined with regular review utilizing:
1. Validate costs include Patient Reported Outcome & Morbidity (PROM) data
2. Utilize Financial and Clinical Governance processes to support tariffs
Clear tariff structures:
1. Individual and family pay as you go
2. Self-pay care packages
3. Insured care packages (agreed with insurance companies)
4. Insured as you go scheme
5. Company packages (e.g. direct with airlines, hospitality, engineering)
Service Development Promotion and Expansion:
1. Advertisement, brochures, website updates, podcasts
2. Patient Information Leaflets (PILs)
3. Meet the expert public promotion meetings
4. Ask the experts online Q&A
5. Patient service user feedback and testimonials
6. Publish favourable audit data
Quality Assurance and Clinical Governance
Specialist Doctors, Nursing, Midwifery PG training, CPD updates, regular
attendance at relevant meetings
1. Personal and service audit
2. Demonstrate compliance with service Care Pathways
3. Attend regular MDT and divisional governance meetings (>70% per annum)
4. Annual appraisal of team members
5, Formal CPD with regular review to meet local CME requirements
6. Mandatory attendance at UG/PFDs ASM every 1-2 years
7. Participate in service development, pathway updates, audit (patient satisfaction)
Staff recruitment for service expansion and training:
Postgraduates:
1. Specialist trainees undertaking RCOG ATSM (1 year fellowship) UG
2. Recruit then to specialist post 2 years higher training (would include audit/
research component)
3. Recruit consultants from in-house and overseas ‘trained pool’
4. Midwives/CNS: Recruit in-house midwives/ staff nurses to train as continence
perineal/urodynamic specialists. Advancement and pay rise on completion if stay for
2 years minimum.
5. Attract undergraduates: Special Skills Modules in UG and PFDs
Capital costs equipment, maintenance, consumable costs, patient safety,
risk, staff training:
1. Outpatient flexible cystoscopy equipment
2. Urodynamics equipment
3. Anal physiology equipment
4. Ultrasound (trans-perineal, anal, trans-vaginal transducers)
5. MRI imaging
Lease equipment, replace and upgrade every 5 years, regular maintenance
(contracts), review consumables used and procurement costs regularly (includes
single use theatre devices), regular staff training updates, review equipment
related risk incidents, test protocols including sepsis, morbidity and patient safety.M Fynes V1 2018
Summary of
Corporate and
Clinical Governance
aspects of proposed
Uro-Gynaecology and
Pelvic Floor Disorders
Unit

16. Current and future challenges for
Uro-Gynaecology services:
1. Consent
2. Information Governance (registries)
3. Providing patients with a range of treatment options
4. Managing patient expectations
5. Mesh complications
6. Training the next generation

17. Consent Uro-Gynaecology surgery:
1. Montgomery ruling
3. Consent form
4. Cooling off period
5. Patient Information Leaflets (PILs)
6. Use of electronic records
7. Patient letters
8. Personal audit versus published audit patient data on
success failure and morbidity
9. Duty of candor
10. What medico-legally constitutes informed consent?

19. Mesh problems
1. Mesh inserted vaginally for stress urinary
incontinence (e.g. TVT TOT)
2. Mesh inserted for prolapse correction vaginally
(e.g. apogee, prolift kits)
3. Abdominal insertion mesh (sacrocolpopexy)

25. Training the next generation:
1. Robust 1-year fellowships RCOG ATSM Uro-Gynaecology.
2. Competitive appointment two year fellowships for more
advanced training leading to an MSc for Uro-Gynaecology
or Uro-Obstetrics linked with UAE University Al Ain.
3. Fixed contracts for postgraduate training.
4. Medical students Special Skills Module (SSM) or
equivalent to stimulate interest and research in this area
(linked to the medical school).
5. Regular audit and annual research and study days.
6. Opportunities to work overseas for a fixed period.

26. Summary
Mapping and monitoring the service:
1. Integrated Governance structures/processes
2. Good communication
3. Robust IT
4. User friendly electronic records platform that is adaptable
and facilitates audit
5. Regularly updated interactive website
6. Involving patients in all aspects of their care and
incorporating their feedback into service changes and
development.

27. Overview of
proposed
Corniche Hospital
Uro-Gynaecology
and
Female Pelvic Floor
Disorders service
CEO Corniche Hospital
Follow-up at Corniche Follow-up at Corniche
M Fynes iv.2018
Corniche Hospital Surgical Care: Ambulatory, Day
Case, or inpatient, under local, regional or general
anaesthesia (preferably dedicated anaesthetist team)

28. Any
Questions?