2. 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

3. 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

4. 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)

5. 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

6. 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?

7.  Abdominal and bimanual examination

8. 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

9. 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

10. Disorders of the urinary tract

11. 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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. Mixed USI & Overactive bladder   10% of all incontinence cases   Most bothersome symptom treated first

18. 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

19. Chronic retention and overflow   Urethral obstruction or detrusor inactivity   Pelvic masses and incontinence surgery common causes   Autonomic neuropathis (diabetes)   Rx: intermittent self catheterisation

20. 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

21. 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

22. Symptoms  Vasomotor  Hot flushes, night sweats(70%)  Urogenital  Vaginal atrophy, dyspareunia, itching, burning, dryness  Frequency, urgency, nocturia, incontinence  Sexual problems – desire  Osteoporosis  Osteoporotic fractures

23. 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

24. 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

25. 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)

26. Risk factors  Exogenous oestrogens (without progestogen)  Obesity (androgens -> oestrogens)  PCOS  Nulliparity  Late menopause  Tamoxifen  COCP is a PROTECTIVE factor

27. Investigations  Presentation usually PMB, IMB or irregular bleeding  USS/TVS  If endometrium >4mm pipelle or hysteroscopy.  Biopsy required for diagnosis

28. Staging 1Uterus only 1A< ½ myometrial invasion 1B> ½ myometrial invasion 2Cervix involved 3Pelvic/para-aortic lymph nodes 4Bowel and bladder or distant spread

29. 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

30. 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

31. 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

32. Treatment  Dependant on stage  Surgery or chemo-radiotherapy  Overall, 65% 5 year survival rate

33. 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

34. Presentation  Often vague or absent  Persistent abdominal distention  Pelvic or abdominal pain  Urinary urgency/frequency  IBS symptoms  O/E  Cachexia, pelvic mass, ascites

35. Investigations  CA125 measurement  If >35IU/mL -> USS abdomen  Risk of malignancy index calculated (RMI)  USS score, menopausal status, CA125 levels  CT pelvis and abdomen

36. 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

37. Management  Surgical  Midline laparotomy  Chemotherapy  CA125 levels can be used to monitor response to chemotherapy