Urthrocele Lower anterior vaginal wall Involving urethra only Cystocele Upper anterior vaginal wall Involving bladder Urethrocystocele As above with associated prolapse of ID: 496807
Download Presentation The PPT/PDF document "Types of prolapse" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1Slide2
Types of prolapse
Urthrocele
Lower
anterior vaginal wallInvolving urethra onlyCystoceleUpper anterior vaginal wallInvolving bladderUrethrocystoceleAs above with associated prolapse of urethraSlide3
Types of prolapse
Apical prolapse
Prolapse of the uterus
, cervix and upper vaginaOr of the vaultEnteroceleUpper posterior wallof the vaginaResulting pouch usuallycontains loops of small bowel
Rectocele
Lower posterior
wall of vaginaInvolving anterior wall of the rectumSlide4
Pelvic organ prolapse scoring system
Patient must be:
Standing at rest, straining, traction employed
0No descent of pelvic organs during straining 1Leading surface of prolapse does not descend below 1cm above the hymenal
ring
2
Ledaing
edge of prolapse extends from 1cm above to 1cm below the
hymenal
ring
3
Prolapse extends 1cm or more below the
hymenal
ring but without complete vaginal eversion
4
Vagina completely
everted
(complete
procidentia
)
Slide5
Aetiology of prolapse
Vaginal delivery and pregnancy
Mechanical injuries, denervation
Large infantsProlonged second stageInstrumental deliveryIncreased ageCongenitalEhlers-DanlosChronic predisposing factors – increasing intra-abdominal pressureObesityChronic cough, constipation, heavy liftingIatrogenicPelvic surgery, hysterectomy Slide6
Clinical features
Dragging sensation
or lump sensation
Interferes with intercourse if severeUrinary frequency if cysourethroceleStress incontinence?difficulty defecating – rectoceleWhat examination would you perform?Slide7
Abdominal and bimanual examinationSlide8
Investigation and management
Pelvic ultrasound
Urodynamic testing
Fitness for surgeryWeight reduction, physiotherapy?Ring pessary or shelf pessary (more effective for severe prolapseMay cause pain, urinary retention Surgical Slide9
Surgical treatment
Uterine prolapse
Vaginal
hysterectomy but…. 40% then have vaginal vault prolapse…HYSTEROPEXYUterus and cervix attached to the sacrum using a non-absorbable meshVaginal vault prolapseSacrocolpopexyFixes vault to sacrumComplications: mesh erosion, haemorrhageSacrospinous fixation (vaginally)Suspends vault to sacrospinous ligamentVaginal wall prolapseAnterior/posterior repair
Urodynamic incontinence
TVT –
Tension-free vaginal tape
Or,
Burch
colposuspension
Usually at same time as prolapse repairSlide10
Disorders of the urinary tractSlide11
Urinary stress incontinence
Confirm by
urodynamic studies
-> Urodynamic stress incontinenceSlide12
Examination and Investigation
O/E
May reveal cystocele or
urethroceleLeakage with coughingPalpate abdomenExclude distented bladder (overflow)IxDipstick – exclude infectionUrodynamic studiesCystometry – exclude overactive bladderSlide13
Management
Encourage weight loss if
obese
Stop smoking (chronic cough)Reduce excessive fluid intakePelvic floor muscle training 8 x dailyVaginal conesDuloxetine (SNRI)SEs: dyspepsia, dry mouth, dizziness, insomnia, drowsinessSurgery if conservative and pharmacological failedTVT – tension-free vaginal tape or TOT transobturator tape(
more effective than
burch
colposuspension)Slide14
Overactive bladder
Urgency
with or without urge incontinence, usually with
frequency or nocturiaSymptoms suggestive of DETRUSOR OVERACTIVITYDetrusor overactivity during the FILLING STAGEMay be spontaneous or provoked e.g. coughing (post-cough)Not all with OAB have detrusor overactivity (and vica versa)Often idiopathicCan follow USI (urinary stress incontinence) operationsOAB may be due to involuntary detrusor contractions (detrusor overactivity..)
May occur in presence of disease e.g. MS or spinal cord
injurySlide15
Investigations
History
Urge and urge incontinence
Leak at night or orgasmHx of childhood enuresis commonExaminationOften normal. ?indicental cystoceleInvestigationsUrinary diary: caffeinated drinks? Frequent passage of small amounts of urineCystometry: contractions on filling or provocationSlide16
Management
Reduce fluid
and caffeine intake
Bladder training i – educationii – timed voiding with systematic delay in voidingiii – positive reinforcementAnticholingics(antimuscarinics) e.g. oxybutynin, tolterodine, solifenacinFor nocturia – desmopressinBotulinium toxin A
Blocks neuromuscular transmission
Injected
cystoscopically – 10-30 locations, duration 6 monthsComplication -
retention
Oestrogens
Women often develop symptoms after the menopause
Oestrogen reduces urgency, urge incontinence, frequency and
nocturiaSlide17
Mixed USI & Overactive bladder
10% of all incontinence cases
Most bothersome symptom treated firstSlide18
Acute urinary retention
Unable to pass urine for
12hr
or moreCatheterisation produces more urine than the normal bladder capacityPainful (except when due to epidural anaesthesia)Due to: childbirth, pelvic masses, neurological diseaseSlide19
Chronic retention and overflow
Urethral obstruction or detrusor inactivity
Pelvic masses and incontinence surgery common causes
Autonomic neuropathis (diabetes)Rx: intermittent self catheterisationSlide20
Painful bladder syndrome and interstitial cystitis
PBS:
surprapubic
pain related to filling of bladderAbsence of UTI or other obvious pathologyInterstitial cystitis: PBS plus characteristic cystoscopic changesRx: bladder trainingTricyclic antidepressantsanalgesicsSlide21
The menopause
The permanent cessation of menstruation
Median age of 51
Early menopauseBefore age 40 – 1% of womenPerimenopauseFrom the first feature of the menopause until 12 months after the LMPPost-menopause12 months after LMPSlide22
Symptoms
Vasomotor
Hot flushes, night sweats(70%)
UrogenitalVaginal atrophy, dyspareunia, itching, burning, drynessFrequency, urgency, nocturia, incontinenceSexual problems – desireOsteoporosisOsteoporotic fracturesSlide23
Post menopausal bleeding
Vaginal bleeding occurring at least 12 months after the LMP
Causes
Endometrial carcinomaCervical carcinomaEndometrial hyperplasia – atypia and polyps (pre-malignant)Atrophic vaginitisCervitisOvarian carcinomaCervical polypsSlide24
Investigations
Bimanual, Speculum and Abdominal examinations
Cervical smear
Transvaginal sonographyIf >4mm or multiple bleeds then endometrial biopsy and hysteroscopy requiredBiopsy using pipelleIf malignancy excluded, rx. Atrophic vaginitis with topical oestrogenSlide25
Endometrial carcinoma
Most common
genital tract cancer
Highest prevalence age 6015% occur premenopausaly<1% in women <35>90% Adenocarcinoma of columnar endometrial glad cellsOthers – adenosquamous carcinomaAetiologyHigh or unopposed oestrogen levels (no progesterone)Slide26
Risk factors
Exogenous oestrogens (without
progestogen
)Obesity (androgens -> oestrogens)PCOS NulliparityLate menopauseTamoxifenCOCP is a PROTECTIVE factorSlide27
Investigations
Presentation usually PMB, IMB or irregular bleeding
USS/TVS
If endometrium >4mm pipelle or hysteroscopy.Biopsy required for diagnosisSlide28
Staging
1
Uterus only
1A< ½ myometrial invasion1B> ½ myometrial invasion2Cervix involved3Pelvic/para
-aortic
lymph nodes
4Bowel and bladder or
distant spreadSlide29
Cervical carcinoma
90% Squamous cell carcinoma
Pre-invasive stage –
Cervical intraepithelial neoplasiaPeak incidence 25-29 yearsIf untreated approx… 1/3 women with CIN II/III will develop cervical cancer over the next 10 yearsScreening – All womenEvery 3 years from 25-49Every 5 years from 50-64Slide30
History and examination
Post coital bleeding
or
PMBPain is a late featureSmear tests often missedUlcer or mass may be visible or palpable on the cervixDiagnosis made by biopsy or LLETZSlide31
Staging
1
Cervix and uterus
1a(i)<3mm depth1a(ii)<7mm across1a(iii)<5mm depth1brest2
Upper vagina also
2a
Not parametrium
2b
In
parametrium
3
Lower vagina or pelvic wall or ureteric obstruction
4
Into bladder or rectum,
or beyond pelvisSlide32
Treatment
Dependant on stage
Surgery or chemo-radiotherapy
Overall, 65% 5 year survival rateSlide33
Ovarian Carcinoma
Risk factors relate to number of ovulations
Early menarche
Late menopauseNulliparityMay be familial – BRCA1, BRCA2Protective factorsPregnancy and lactationThe pillSlide34
Presentation
Often vague or absent
Persistent abdominal
distentionPelvic or abdominal painUrinary urgency/frequencyIBS symptomsO/ECachexia, pelvic mass, ascitesSlide35
Investigations
CA125 measurement
If >35IU/mL -> USS abdomen
Risk of malignancy index calculated (RMI)USS score, menopausal status, CA125 levelsCT pelvis and abdomenSlide36
Staging
1
Macroscopically confined to ovaries
2Beyond ovaries but confined to pelvis3Beyond pelvis but confined to abdomen. Omentum and small bowel frequently involved4Beyond abdomen. E.g. lungs or liver parenchymaSlide37
Management
Surgical
Midline laparotomy
ChemotherapyCA125 levels can be used to monitor response to chemotherapy