Why does Dubai need a Subspecialist Uro-Gynecology and Pelvic Floors Disorders unit?

1. Uro-Gynecology from
Cambridge to Dubai

2. Are there any existing UAE
Uro-Gynecology Services?
Detailed Google search:
22 medical centers and hospitals across the UAE are cited
on the internet as providing treatment for female
incontinence and/or vaginal prolapse.
On analysis of the cited specialists and services:
• There is no dedicated or subspecialist supported
Uro-Gynecology and Female Pelvic Floor Disorders
centre in the UAE.
• There are no subspecialist accredited
Urogynecology consultant(s) practicing within
the UAE.

3. What is a Uro-Gynecologist?
Definitions:
Uro-Gynecology (UG) – Is a sub-speciality of gynecology dealing
with benign disorders of the lower urinary, genital tract and
Pelvic Floor, mainly urinary incontinence and genital prolapse.
A Uro-Gynecologist:
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 Uro-Gynecology and 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. Records all surgical data on an electronic register and audits their practice
(e.g. Using the BSUG or IUGA electronic data base and surgical audit tools).
8. Undertakes annual appraisal demonstrating a proportion of CME in UG.

4. Career background
From Employing University Hospital
2017-2018 Consultant Gynecologist, Urogynecologist, Paediatric Adolescent Gynecologist and Reproductive Medicine
Specialist at Cambridge University Teaching Hospital(s) NHS Foundation Trust (CUHFT), Cambridge UK.
2003-2016 Consultant Urogynecologist, Reconstructive Pelvic Surgeon, Perineal/Childbirth Injury, Paediatric Adolescent
Gynecology at 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 Gynecology at St. Georges University of London, London, UK.
2003-2012 Uro-Gynecology 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 Urogynecology by the RCOG.
1999-2002 Subspecialty training programme completed. Subspeciality accredited by RANZCOG being awarded a
Diploma in Urogynaecology.
2000-2001 Consultant Gynecologist, 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 & Gynecology, Cambridge University, Cambridge, UK.
1996 Membership of the Royal College of Obstetricians and Gynecologists (MRCOG).
1995 Lecturer Obstetrics & Gynecology, University College Dublin, National Maternity Hospital, Ireland.
Dr Michelle 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. Why does Dubai need a Subspecialist Uro-Gynecology 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-Gynecology 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.‘

6. Why does Dubai need a Pelvic Health after Childbirth Clinic?
Postnatal bladder problems affects:- 1 in 4 women
- Stress Urinary Incontinence affects 1 in 5 women
- Over Active Bladder including Urgency and Urge Urinary
Incontinence affects 1 in 5
- Difficulty emptying the Bladder affects 1 in 10
- 1 in 20 women report recurrent urinary infections or cystitis
symptoms after childbirth.
Pelvic Organ Prolapse (POP) affects:- 1 in 5 women
Obstetric Anal Sphincter Injury (OASI):-
- Affects 10% women during 1st vaginal delivery.
- 20% report altered bowel continence ( bowel urgency and
urge related incontinence).
- 30% of these women report significant bladder symptoms
including urinary incontinence.
- 5% of women affected will sustain another anal sphincter
muscle tear at next delivery, are identifiable, and need
antenatal counselling regarding mode of delivery.
‘Effective peri-partum care requires a detailed understanding of normal and
abnormal bladder, bowel, and pelvic floor muscle and sexual function in order to
provide the right care package , at the right time, for the right patient, by the right
doctor. This Childbirth related service provided by Al Zahra Hospital will be the
first of it’s kind and set the Gold Standard for care across the UAE ‘
Pelvic Health after Childbirth Clinics provide treatment for;
1. Women with Bladder problems:
-Pregnancy related Urinary Incontinence
-Pregnancy related Over Active Bladder symptoms (urge frequency urge incontinence)
- Repeated urinary infections/cystitis
- Bladder emptying problems (voiding difficulty)
- Painful Bladder Syndrome
2. Women with Bowel problems:
- Childbirth injury including anal sphincter injury (3rd and 4th degree perineal tears)
- Bowel incontinence, defecatory difficulty, bowel urgency and urge incontinence
- Haemorrhoids and/or Fissure in ano (rectal bleeding and/or pain)
3. Other pregnancy related Pelvic Floor Problems including;
-Prolapse of the uterus and/or vaginal walls both antenatal and postnatal
- Pelvic and/or vaginal pain
4. Problems related to Episiotomy or Perineal Tears;
- Infection or wound breakdown
- Acute, Chronic and/or Sexual Pain
- Vaginal, Perineal and Labial distortion or asymmetry (both functional and cosmetic issues)
- Labial and/or vaginal cysts
5. Counselling: Assessment of women with incontinence, prolapse, a history of
significant perineal tears (e.g. 3rd and 4th degree tear), and/or problems related to repair,
as well as counselling regarding optimal mode of delivery in subsequent pregnancies.

7. What spectrum of conditions will the Al Zahra subspecialist
Uro-Gynecology and Pelvic Floor Disorders Unit treat?
Sexual dysfunction (e.g. dyspareunia, vaginismus, loss of libido)
Bowel disorders
• Incontinence
• Defecatory difficulty
Childbirth injury (e.g. Obstetric Anal Sphincter Injury [OASI],
perineal wound problems, urinary incontinence
obstetric fistula, vaginal laxity, vaginal scarring,
sexual difficulties, abnormal postnatal appearance
of the labia/vagina )
These problems will be effectively treated within specialist clinics
provided by the Urogynecology & Pelvic Floor Disorders Team.
Females of all ages with
Urinary Incontinence & Urogenital Prolapse
Other Lower Urinary Tract Disorders
• Recurrent urinary infection
• Overactive bladder
• Painful bladder disorders
• Difficulty with bladder emptying
• Urogenital fistula
• Urethral diverticula
Complications of Pelvic Organ Prolapse (POP) and
Urinary Incontinence (UI) surgery (e.g. mesh)
Urogenital vaginal and pelvic pain disorders

8. What will the Al Zahra subspecialist Urogynecology and
Pelvic Floor Disorders Unit comprise?
Core Medical Team
• Lead Consultant Obstetrician and
Uro-Gynecologist - Dr Michelle Fynes
• Clinical Nurse specialist
• Women’s Health Physiotherapist(s)
• Perineal Care Midwife
• Link to Colorectal services
• Link to Urology services
• Link to Pain Anaesthetist
• Link to Radiology- Pelvic Floor Imaging
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
Specialist Clinics provided:
1. General Uro-Gynecology and Pelvic Floor Disorders Clinic (all ages)
2. Pelvic Health after Childbirth Clinic (antenatal and up to 12 months postnatal)
3. Paediatric Adolescent Gynecology Clinic (2-18 years)

9. What will the enhanced subspecialist
Uro-Gynecology and Pelvic Floor Disorders
Centre at Al Zahra Hospital Dubai look like?

10. Al Zahra Hospital
Uro-Gynaecology and Female Pelvic Floor Disorders Centre
Referrals seeking appointments
Al-Zahra
MDT Hub
Uro-Gynaecology and
Pelvic Floor Disorders
Service
Pelvic Floor Diagnostics Clinic:
Doctor led alongside Women s Health Physiotherapy
(urodynamics, uroflow, anal manometry, cystoscopy, ultrasound,
pessary management, and minor procedures)
A&E or
Self Referrals
Referralsfrom
physiotherapy on agreed
pathways
In-house referrals
along agreed pathways
Health Clinic Referrals
Family Doctor
Community private clinics
Referralsfrom other hospital
maternity services
Self referrals
(e.g. OASI screening)
Referralsfrom other
Hospitals
Postnatal referralsfrom the
ward or other maternity
hospital services
Referralsfrom antental
or booking clinics
Non-childbirth related:
Adolescent
Premenopausal
Postmenopausal
Elderly care medicine
Childbirth related antepartum
or first 12 months postpartum
Self Referrals
Adolescent or
paediatric urology
referrals or transition
cases referrals
First line conservative therapy including physiotherapy for 3-6 months
minimal investigations formal assessment in clinic 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
Uro-Gynaecology
Surgery (MMF)
Complex
Urologynaecology
surgery requiring
Urology and/or
colorectal input
Outcome:
Symptoms resolved or
improved
and/or patient satisfied
DISCHARGE.
Follow-up
as per care pathway
or discharge to
expectant management
Al Zahra Urogynaecology and Pelvic Floor Disorders Service Model: Fynes V 1-11/2018
REFERRAL:
Colorectal and/or
Urology for assessment
and/or Combined MDT discussion
(sign-off care package)
Urogynaecology
Clinic follow-up
Clinic
discussion
and/or MDT
sign-off
Urogynaecology surgery pathway(s):
(primary or recurrent incontinence, prolapse,
combined incontinence, prolapse, complications etc)
Referrals Al Zahra allocated to one of two clinics:
1. Uro-Gynaecology and Female Pelvic Floor Disorders clinic
2. Childbirth Injury and Perineal Clinic (childbirth related issues)
From there assessed and assigned to correct onward pathway;-
General Urogynaecology and Pelvic Floor Disorders referrals Childbirth related referrals
1. Urogynaecology Surgery needed
join surgery carepathway or
2. MDT review/approval required
Perineal Childbirth
Injury Clinic
Follow-up
Clinic
discussion
and/or MDT
sign-off
CLINIC OUTCOME:
No diagnostics required
patient treated or
advice only
DISCHARGE
Follow-up outcome
Head of Department: Dr Ghassan Lotfi
Service lead: Dr Michelle Fynes
Linked care pathways compliant with ACOG/BSUG/NICE guidance
Al Zahra Hospital
Uro-Gynecology and
Pelvic Floor Disorders
Service Model

11. The Al Zahra
Urogynecology and Pelvic Floor
Disorders Centre:
Will provide treatment for a wide
range of problems using more than
22 condition specific and
regularly updated evidence based
Best Practice Care Pathways
Sample Care Pathway for
Stress Urinary Incontinence

12. Al Zahra Centre and Patient choice:
This subspecialist centre will provide a wide range of treatment
options to patients that are not just evidence based but also
provided by an expert specialist team at Al Zahra Hospital.

13. The Al Zahra Uro-Gynecology and Pelvic
Floor Disorders Service Governance:-
Will be supported by robust processses including:
1. Clinical audit: Incorporating measurable and recorded outcomes
(including QoL).
2. Regular update of Care Pathways.
4. A Multi-Disciplinary Team (MDT) approach to
patient care with regular meetings.
3. Ongoing Education and Training.

14. Mapping and monitoring the service
will incorporate:
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.

15. In summary
The Al Zahra Urogynecology and Pelvic Floor Disorders Centre
1. Will be the first comprehensive subspecialist centre of it’s kind within
Dubai and across the UAE.
2. This service will provide expert care to women of all ages with
bladder and/or bowel incontinence symptoms and pelvic floor disorders.
3. A separate specialist clinic within this centre will be provided for women
affected by continence and pelvic floor problems related to childbirth.
4. A separate specialist clinic will also be provided for children and
adolescents with incontinence or other gynaecology problems.
This service will set the ‘Gold Standard’ for care across the UAE

16. Source of NEW referrals?
Education, Health Promotion and Advertisement
How to reach women of all ages?
A website page with signposting on the Al Zahra website
Podcasts
Patient education seminars
Peer support groups
Patient Information Leaflets (PILs) in all clinical areas
Articles on Women s Health websites (e.g. ex-patriot women s
website pages)
Women s Magazines articles/other media
Twitter and facebook
How to reach other Doctors and referrers?
Study evenings/day programs with CME accreditation
Advertise services
Publish promote audit data
Expanding or ‘Growing’
the Al Zahra
‘Uro-Gynecology
Pelvic Floor service’
and the referral base?

17. Any
Questions?