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Types of prolapse Urthrocele Lower anterior vaginal wall Involving urethra only Cystocele Upper anterior vaginal wall Involving bladder Urethrocystocele As above with associated prolapse of urethra
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Types of prolapse Apical prolapse Prolapse of the uterus, cervix and upper vagina Or of the vault Enterocele Upper posterior wall of the vagina Resulting pouch usually contains loops of small bowel Rectocele Lower posterior wall of vagina Involving anterior wall of the rectum
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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 2Ledaing edge of prolapse extends from 1cm above to 1cm below the hymenal ring 3Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion 4Vagina completely everted (complete procidentia)
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Aetiology of prolapse Vaginal delivery and pregnancy Mechanical injuries, denervation Large infants Prolonged second stage Instrumental delivery Increased age Congenital Ehlers-Danlos Chronic predisposing factors – increasing intra-abdominal pressure Obesity Chronic cough, constipation, heavy lifting Iatrogenic Pelvic surgery, hysterectomy
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Clinical features Dragging sensation or lump sensation Interferes with intercourse if severe Urinary frequency if cysourethrocele Stress incontinence ?difficulty defecating – rectocele What examination would you perform?
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Abdominal and bimanual examination
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Investigation and management Pelvic ultrasound Urodynamic testing Fitness for surgery Weight reduction, physiotherapy? Ring pessary or shelf pessary (more effective for severe prolapse May cause pain, urinary retention Surgical
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Surgical treatment Uterine prolapse Vaginal hysterectomy but…. 40% then have vaginal vault prolapse… HYSTEROPEXY Uterus and cervix attached to the sacrum using a non-absorbable mesh Vaginal vault prolapse Sacrocolpopexy Fixes vault to sacrum Complications: mesh erosion, haemorrhage Sacrospinous fixation (vaginally) Suspends vault to sacrospinous ligament Vaginal wall prolapse Anterior/posterior repair Urodynamic incontinence TVT – Tension-free vaginal tape Or, Burch colposuspension Usually at same time as prolapse repair
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Disorders of the urinary tract
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Urinary stress incontinence Confirm by urodynamic studies -> Urodynamic stress incontinence Bladder neck below pelvic floor During increased intra-abdominal pressure, pelvic floor and urethra unable to compensate Bladder pressure exceeds urethral pressureIncontinence results
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Examination and Investigation O/E May reveal cystocele or urethrocele Leakage with coughing Palpate abdomen Exclude distented bladder (overflow) Ix Dipstick – exclude infection Urodynamic studies Cystometry – exclude overactive bladder
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Management Encourage weight loss if obese Stop smoking (chronic cough) Reduce excessive fluid intake Pelvic floor muscle training 8 x daily Vaginal cones Duloxetine (SNRI) SEs: dyspepsia, dry mouth, dizziness, insomnia, drowsiness Surgery if conservative and pharmacological failed TVT – tension-free vaginal tape or TOT transobturator tape ( more effective than burch colposuspension)
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Overactive bladder Urgency with or without urge incontinence, usually with frequency or nocturia Symptoms suggestive of DETRUSOR OVERACTIVITY Detrusor overactivity during the FILLING STAGE May be spontaneous or provoked e.g. coughing (post-cough) Not all with OAB have detrusor overactivity (and vica versa) Often idiopathic Can follow USI (urinary stress incontinence) operations OAB may be due to involuntary detrusor contractions (detrusor overactivity..) May occur in presence of disease e.g. MS or spinal cord injury
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Investigations History Urge and urge incontinence Leak at night or orgasm Hx of childhood enuresis common Examination Often normal. ?indicental cystocele Investigations Urinary diary: caffeinated drinks? Frequent passage of small amounts of urine Cystometry: contractions on filling or provocation
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Management Reduce fluid and caffeine intake Bladder training i – education ii – timed voiding with systematic delay in voiding iii – positive reinforcement Anticholingics(antimuscarinics) e.g. oxybutynin, tolterodine, solifenacin For nocturia – desmopressin Botulinium toxin A Blocks neuromuscular transmission Injected cystoscopically – 10-30 locations, duration 6 months Complication - retention Oestrogens Women often develop symptoms after the menopause Oestrogen reduces urgency, urge incontinence, frequency and nocturia
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Mixed USI & Overactive bladder 10% of all incontinence cases Most bothersome symptom treated first
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Acute urinary retention Unable to pass urine for 12hr or more Catheterisation produces more urine than the normal bladder capacity Painful (except when due to epidural anaesthesia) Due to: childbirth, pelvic masses, neurological disease
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Chronic retention and overflow Urethral obstruction or detrusor inactivity Pelvic masses and incontinence surgery common causes Autonomic neuropathis (diabetes) Rx: intermittent self catheterisation
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Painful bladder syndrome and interstitial cystitis PBS: surprapubic pain related to filling of bladder Absence of UTI or other obvious pathology Interstitial cystitis: PBS plus characteristic cystoscopic changes Rx: bladder training Tricyclic antidepressants analgesics
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The menopause The permanent cessation of menstruation Median age of 51 Early menopause Before age 40 – 1% of women Perimenopause From the first feature of the menopause until 12 months after the LMP Post-menopause 12 months after LMP
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Symptoms Vasomotor Hot flushes, night sweats(70%) Urogenital Vaginal atrophy, dyspareunia, itching, burning, dryness Frequency, urgency, nocturia, incontinence Sexual problems – desire Osteoporosis Osteoporotic fractures
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Post menopausal bleeding Vaginal bleeding occurring at least 12 months after the LMP Causes Endometrial carcinoma Cervical carcinoma Endometrial hyperplasia – atypia and polyps (pre-malignant) Atrophic vaginitis Cervitis Ovarian carcinoma Cervical polyps
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Investigations Bimanual, Speculum and Abdominal examinations Cervical smear Transvaginal sonography If >4mm or multiple bleeds then endometrial biopsy and hysteroscopy required Biopsy using pipelle If malignancy excluded, rx. Atrophic vaginitis with topical oestrogen
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Endometrial carcinoma Most common genital tract cancer Highest prevalence age 60 15% occur premenopausaly <1% in women <35 >90% Adenocarcinoma of columnar endometrial glad cells Others – adenosquamous carcinoma Aetiology High or unopposed oestrogen levels (no progesterone)
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Risk factors Exogenous oestrogens (without progestogen) Obesity (androgens -> oestrogens) PCOS Nulliparity Late menopause Tamoxifen COCP is a PROTECTIVE factor
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Investigations Presentation usually PMB, IMB or irregular bleeding USS/TVS If endometrium >4mm pipelle or hysteroscopy. Biopsy required for diagnosis
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Staging 1Uterus only 1A< ½ myometrial invasion 1B> ½ myometrial invasion 2Cervix involved 3Pelvic/para-aortic lymph nodes 4Bowel and bladder or distant spread
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Cervical carcinoma 90% Squamous cell carcinoma Pre-invasive stage – Cervical intraepithelial neoplasia Peak incidence 25-29 years If untreated approx… 1/3 women with CIN II/III will develop cervical cancer over the next 10 years Screening – All women Every 3 years from 25-49 Every 5 years from 50-64
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History and examination Post coital bleeding or PMB Pain is a late feature Smear tests often missed Ulcer or mass may be visible or palpable on the cervix Diagnosis made by biopsy or LLETZ
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Staging 1Cervix and uterus 1a(i)<3mm depth 1a(ii)<7mm across 1a(iii)<5mm depth 1brest 2Upper vagina also 2aNot parametrium 2bIn parametrium 3Lower vagina or pelvic wall or ureteric obstruction 4Into bladder or rectum, or beyond pelvis
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Treatment Dependant on stage Surgery or chemo-radiotherapy Overall, 65% 5 year survival rate
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Ovarian Carcinoma Risk factors relate to number of ovulations Early menarche Late menopause Nulliparity May be familial – BRCA1, BRCA2 Protective factors Pregnancy and lactation The pill
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Presentation Often vague or absent Persistent abdominal distention Pelvic or abdominal pain Urinary urgency/frequency IBS symptoms O/E Cachexia, pelvic mass, ascites
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Investigations CA125 measurement If >35IU/mL -> USS abdomen Risk of malignancy index calculated (RMI) USS score, menopausal status, CA125 levels CT pelvis and abdomen
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Staging 1Macroscopically confined to ovaries 2Beyond ovaries but confined to pelvis 3Beyond pelvis but confined to abdomen. Omentum and small bowel frequently involved 4Beyond abdomen. E.g. lungs or liver parenchyma
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Management Surgical Midline laparotomy Chemotherapy CA125 levels can be used to monitor response to chemotherapy
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