1. GENITAL PROLAPSE DR. IQBAL TURKISTANI Asst. Prof. & Consultant

2. ♣ The pelvic floor, closing the outlet of the pelvis is made up of a number of muscular and facial structures  the most important of which is the LEVATOR ANI. ♣ These structures are pierced by the RECTUM, VAGINA & URETHRA.  passing through the exterior of the body ♣ These structures are supported in place by: -ligaments -condensation of facia

3. ♣ A relaxed vaginal outlet is usually a sequel to mere  OVERSTRETCHING of the perineal supporting tissues as a result of previous parturition  Muscular atony and loss of elastic tissue in later life  lack of hormone  DENERVATION due to damage to perineal or pelvic nerves  delivery and pelvic surgery

4. TYPES OF GENITAL PROLAPSE PELVIC ORGAN PROLAPSE (POP) 1.CYSTOCELE = As a result of defect in the pubo-cervical facial plane which support the bladder anteriorly = it tends to permit the bladder to sag down below and beyond the uterus = it tends to permit the bladder to sag down below and beyond the uterus 2.URETHROCELE: = when the defective facia involves the urethra 3.RECTOCELE = due to attenuation in the pararectal facia  permits the rectum to bulge through 4.ENTEROCELE: =Peritoneal hernial sac along the anterior surface of the rectum = Often contains loops of small intestine

5. DIAGNOSIS OF POP SYMPTOMS:  Often symptomless  Complaints of : Pressure and heaviness in the vaginal region Pressure and heaviness in the vaginal region Sensation of “everything dropping out” Sensation of “everything dropping out” Bearing down discomfort in the lower abdomen Bearing down discomfort in the lower abdomen Backache Backache

6.  Other associated problems: Fecal incontinence (e.g. with complete perineal laceration) and often with loose stools. Fecal incontinence (e.g. with complete perineal laceration) and often with loose stools. Difficulty in emptying the bladder with marked cyctocele Difficulty in emptying the bladder with marked cyctocele Cystitis  due to residual urine Cystitis  due to residual urine  ascending UTI  frequency of micturition Urinary incontinence  stress incont. Urinary incontinence  stress incont. Difficulty of defection and constipation with rectocele Difficulty of defection and constipation with rectocele  haemorrhoids  Lump/mass protruding through  is marked prolapse

7. SIGNS / EXAMINATION:  Inspection Gaping introitus Gaping introitus Perineal scars Perineal scars Visible cystocele and rectocele / urethral Visible cystocele and rectocele / urethral Uterine prolapse Uterine prolapse  Cx. Ulceration (contact) =Decubitus ulcer Degree of prolapse

10. TREATMENT Incontinence POP Incontinence POP Objective: To provide cure or improvement Treatment options, risks, benefits and outcomes should be discussed. Treatment Options: Can be divided into: PharmacologalConservative Surgical Measures intenvention I.CONSERVATIVE TREATMENT:  Life style interventions  Physical therapy (PFMT) / Kegel’s Exercise  Bladder training  Electrical stimulation  Behavioral strategies  Anti- incontinence devices

11. II.PHARMACOLOGICAL TREATMENT: A. Drug used for Urgency Incont. and OAB. i. Antimuscarinic (anticholinergic) agents - Muscanic receptors (M2 & M3) are predominant in the bladder. - Muscanic receptors (M2 & M3) are predominant in the bladder. - These can be blocked by antimuscarinic which act by - These can be blocked by antimuscarinic which act by competing with ACH on the muscarinic receptors mainly during the storage phase competing with ACH on the muscarinic receptors mainly during the storage phase e.g. Oxybutinin Tolterodine SolifenacinTertiary amines Darifanacin Propiverine  Quarternary amines - Very good efficacy profile - Side effects :  Dry mouth  Constipation  Blurred Vision & Cardiovascular effect – palpitations / tachycardia & Cardiovascular effect – palpitations / tachycardia - Contraindication : , Narrow angle glucoma , Narrow angle glucoma

12. ii. Botulinum Toxin (BTX) - types A & B - local intravesical injection - local intravesical injection - Blocks the release of Ach from parasympathetic nerve endings at the myo-neuronal junction  redution in - Blocks the release of Ach from parasympathetic nerve endings at the myo-neuronal junction  redution in muscle contractility muscle contractility B.DRUGS FOR SUI: Duloxetine = combined norepinephrine and serotonin re-uptake inhibitor   sphincter muscle activity during filling phase of micturition  significant  in incont. episode frequency (IEF) >50% from baseline ---> improvement in quality of life SIDE EFFECTS: -Nausea -Others  fatigue, dry mouth, headache, dizzines C.ESTROGENS = Controversiial  little effect in the management of SUI

13. SURGICAL TREATMENT FOR INCON. I.SURGERY FOR SUI: 1.Intra-urethral injection therapy 2.Cysto-urethropexies 3.Low-tension vaginal tape -TVT -TOT 4.Classical sling procedures 5.Artificial sphincters II.SURGERY FOR URGNECY INCONT. (UUI) 1.Augmentation cystoplasty 2.Auto-augmentation 3.Sacral nerve stimulation