P ROLAPSE & U ROGYNECOLOGY Dr:Sa’adeh S. Jaber MBBS, MRCOG,MRCPI Consultant Gynecology...

PROLAPSE amp UROGYNECOLOGY

DrSarsquoadeh S Jaber

MBBS MRCOGMRCPI

Consultant Gynecology ampObstetric

Makased Islamic Charitable hospital

PELVIC ANATOMY

RISK FACTORS

1048697 Vaginal delivery 1048697 Age ----- menopause 1048697 Previous prolapsed surgery 1048697 Other 1048697 Physical stress 1048697 Increase intra-abdominal pressure

DIAGNOSIS

1048697 History taking 1048697 Physical examination 1048697 Pelvic examination

stage Description

0 No descensus of pelvic structure during straining

Ⅰ The leading surface of the prolapse does not descend below 1 cm above the hymenal ring

Ⅱ The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring

Ш The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion

Ⅳ The prolapse extends more than 1 cm beyond the hymenal ring but not complete vaginal eversion

TREATMENT

1048697 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries 1048697 Surgical treatment

URINARY INCONTINENCE Definition - (ICS)

involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem

Incidence -

10-25 among population 15-64 years of age

Up to 45 around age of 70- 80

ETIOLOGY Multifactorial Reversible causes

delirium infection atrophic vaginalis drugs endocrine disorder bed ridden stool

impaction Anatomic defect

genuine stress incontinence

urethral sphincter incontinence

ectopic ureter

fistula Neurological defect

Detrusor instability Bladder hyperreflexia

CLASSIFICATION

Stress urinary incontinence Detrusor instability or overactive bladder Mixed UI Overflow UI Functional UI Bypass of the anatomic continence

mechanism

CLINICAL EVALUATION

History - Onset hellipgradual ------ atrophy abrupt ------- infection - Duration - Severity quality of life - Related symptoms--- urgency frequency nocturia

enuresis - Triggering circumstances

key in the door intercourse helliphellip- Medical history

DM MS CVA thyroid - Parity mode of delivery - Urology pelvic surgery - Psychiatric history

CLINICAL EVALUATION (CONT)

Physical examination A- Routine Exam

nutritional status mental statusmobility presence of hernia neurologic exam

B- Specific Exam

anal wink reflex evaluate integrity of pudendal sacral cord levator ani muscle external anal sphincter DTR helliphellipUMNL------ hyperreflexia

LMNL ----- absence abdominal pelvic mass

C ndash Pelvic Exam

Inspection -atrophy fistulainfection irritation

palpation -vaginal anal sphincter prolapse defects perineal sensation demonstrable urinary

incontinence

INVESTIGATION

1 ndash UA Culture may indicate infection or stone

2 ndash Pad test weighing pad after exercise

3 ndash Provocative testuarr intra abdominal pressure on full bladder

4 ndash Residual volume after void (USS or cath) lt 50 ml ideal lt100 ml acceptable gt200 ml indicate voiding problem as

well as detrusor instability

5 - Uroflowmetry

does not help in diagnosing type of incontenence but indicate if any voiding problems with itrsquos implication

NORMAL VOIDING

OBSTRUCTIVE VOIDING

6 ndash Cystometry = Gold Standard =Demonstrate -

capacity filling phase storage detrusor function

Demonstrate -volume pressure contraction

relationship

Normal -first sensation ------ 150 mlfullness --------------- 200 ndash 300 ml maximal capacity--- 400 ndash 700

ml

7 ndash Video urodynamics cysto flowmetry + radiological

contrast imaging

8 ndash Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation

STRESS INCONTINENCE Definition -

objectively demonstrable UI associated with increased intra abdominal pressure

Incidence -

Diagnosis -History exam urodynamic

assessment Note - bladder is unreliable wittness

D Dx -DI Overflow Extra urethral

MANAGEMENT

1) Conservative When Why amp For how long Diet modification Kegelrsquos exercise electrical stimulation biofeed backring pessaries

2) Medical a- α adrenergic stimulant - may help in mixed UI Like Pseudoephedrine

Imipramine Phenylprpanalamine b- Oestrogen - uarr urethral receptor sensitivity uarr urethral mucosal thickness

3) SURGICAL -

Overview about principle

a- anterior vaginal wall repair ldquokelly plication

particularly relevant if cystocele present

gt5 year success rate 37complication rate 1voiding problem DI 4

b- Marshall-Marchetti-Krantz urethropexy-

suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 post operative voiding dysfunction 28osteitis pubis

c- Burch colposuspension -

suturing the periurethral tissue to cooperrsquos ligament

initial success rate asymp 90-95 long term success rate 80-90enterocele 8DI 10

modification

d- Bladder neck suspension -(Pereyra stamey Raz )

transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent UIor in previously operated cases

e- TVT

f- Cystoscopic periurethral bulk injection medical collagen (Bovin)50-60 marked improvement minimally invasive procedure 3 of patient are allergic

can be done at bladder neck level ldquopreferablerdquo or at periurethral

meatus

Injection of collagen in the periurethral tissue for the treatment of stress incontinence

g- artificial sphincter

h- urinary diversion

COMPLICATION -

- Urinary retention - uarrresidual volume - Voiding dysfunction - Urge incontinence - Intraoperative bleeding - Infection - Early late rejection of graft - Sling erosion into bladder or urethra

DETRUSOR INSTABILITYInvoluntary detrusor contraction

Unknown etiology -associated with SI bladder outlet

obstruction aging CNS problemIncidence -

5-50 depending on age up to 80 of institutionalized women

Diagnosis- history exam urodynamic study---contraction during

the filling phase

MANAGEMENT

a- behavioral modification

education timed voiding + reinfocement

b- bladder retraining (drill)

resisting urge sensation rarr increase bladder volume by postponing voiding

c- Medical

1) oxybutynin ldquoditropan novitropanrdquo25-5 mg 2or 3 time dailyanticholinergic muscle relaxant40 improvement many side effect

2) Tolterodine (Detrusitol)1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile

3) Imipramin (TCA)10-25 mg 3 time daily particularly relevant in enuresis

coital UI4) HRT plusmn

d- Surgical -

Denervation ldquophenol HydrodisteneionrdquoBladder transsection Ileocystoplasty ldquobladder augmentationrdquoUrinary diversion