P ROLAPSE & U ROGYNECOLOGY Dr:Sa’adeh S. Jaber MBBS, MRCOG,MRCPI Consultant Gynecology &Obstetric Makased Islamic Charitable hospital

P ELVIC ANATOMY

R ISK FACTORS Vaginal delivery Age menopause? Previous prolapsed surgery Other Physical stress Increase intra-abdominal pressure

D IAGNOSIS History taking Physical examination Pelvic examination

stageDescription 0No 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. ШThe prolapse extends more than 1 cm beyond the hymenal ring, but not complete vaginal eversion Ⅳ

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

U RINARY INCONTINENCE Definition :- (ICS) involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem Incidence : % among population years of age Up to 45% around age of

E TIOLOGY 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

C LASSIFICATION Stress urinary incontinence Detrusor instability or overactive bladder Mixed U.I Overflow U.I Functional U.I Bypass of the anatomic continence mechanism

C LINICAL EVALUATION *History - Onset …..gradual atrophy abrupt infection - Duration - Severity, quality of life - Related symptoms--- urgency, frequency, nocturia, enuresis - Triggering circumstances key in the door, intercourse …… - Medical history DM, MS, CVA, thyroid - Parity, mode of delivery - Urology, pelvic surgery - Psychiatric history

C LINICAL EVALUATION ( CONT ) * Physical examination A- Routine Exam nutritional status mental status mobility presence of hernia neurologic exam

B- Specific Exam anal wink reflex, evaluate integrity of pudendal, sacral cord levator ani muscle external anal sphincter DTR ……UMNL hyperreflexia LMNL absence abdominal, pelvic mass

C – Pelvic Exam Inspection :- atrophy fistula infection irritation palpation :- vaginal, anal sphincter prolapse defects perineal sensation demonstrable urinary incontinence

I NVESTIGATION 1 – U/A, Culture may indicate infection or stone 2 – Pad test : weighing pad after exercise 3 – Provocative test: ↑ intra abdominal pressure on full bladder 4 – Residual volume after void (USS or cath) < 50 ml ideal <100 ml acceptable >200 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 it’s implication

N ORMAL VOIDING

O BSTRUCTIVE VOIDING

6 – Cystometry = Gold Standard = Demonstrate :- capacity, filling phase, storage, detrusor function, Demonstrate :- volume, pressure, contraction relationship Normal :- first sensation ml fullness – 300 ml maximal capacity – 700 ml

7 – Video urodynamics cysto, flowmetry + radiological contrast imaging 8 – Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation

S TRESS INCONTINENCE Definition :- objectively demonstrable U.I associated with increased intra abdominal pressure Incidence :- ???????????? Diagnosis :- History, exam, urodynamic assessment Note :- bladder is unreliable wittness D Dx :- DI, Overflow,Extra urethral

M ANAGEMENT 1) Conservative When, Why & For how long Diet modification Kegel’s exercise electrical stimulation biofeed back ring pessaries

2) Medical a- α adrenergic stimulant :- may help in mixed U.I Like,.Pseudoephedrine, Imipramine Phenylprpanalamine b- Oestrogen :- ↑ urethral receptor sensitivity ↑ urethral mucosal thickness

3) S URGICAL :- Overview about principle a- anterior vaginal wall repair “kelly plication particularly relevant if cystocele present >5 year success rate 37% complication rate 1% voiding problem, DI 4%

b- Marshall-Marchetti-Krantz urethropexy:- suturing the periurethral tissue to the periosteum of pubic symphysis success rate % post operative voiding dysfunction 28% osteitis pubis

c- Burch colposuspension :- suturing the periurethral tissue to cooper’s ligament initial success rate ≈ % long term success rate 80-90% enterocele 8% DI 10% *modification

d- Bladder neck suspension :- (Pereyra, stamey, Raz ) transvaginal approach to retropubic space result inbetween Burch and anterior repair particularly relevant in recurrent U.Ior 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 “preferable” or at periurethral meatus

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

g- artificial sphincter h- urinary diversion

C OMPLICATION :- - Urinary retention. - ↑residual volume. - Voiding dysfunction. - Urge incontinence. - Intraoperative bleeding. - Infection. - Early, late rejection of graft. - Sling erosion into bladder or urethra.

D ETRUSOR INSTABILITY Involuntary detrusor contraction. Unknown etiology :- associated with S.I, bladder outlet obstruction, aging, CNS problem Incidence :- 5-50% depending on age up to 80% of institutionalized women Diagnosis:- history, exam, urodynamic study---contraction during the filling phase

M ANAGEMENT a- behavioral modification education timed voiding + reinfocement b- bladder retraining (drill) resisting urge sensation → increase bladder volume by postponing voiding

c- Medical 1) oxybutynin “ditropan, novitropan” mg 2or 3 time daily anticholinergic, muscle relaxant 40% improvement many side effect 2) Tolterodine (Detrusitol) 1-2 mg 1 or 2 time daily muscarinic antagonist better side effect profile 3) Imipramin (TCA) mg 3 time daily particularly relevant in enuresis, coital U.I 4) HRT ±

d- Surgical :- Denervation “phenol, Hydrodisteneion” Bladder transsection Ileocystoplasty “bladder augmentation” Urinary diversion