Types of prolapse - PowerPoint Presentation

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Slide2

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