1. UROGYNAECOLOGY It includes such conditions as urinary incontinance prolapse voiding difficulty frequency&urgency urinary tract infection fistulae.

3. Urodynamics is the active investigation of urinary tract function. Certain conditions cannot be diagnosed on clinical presentation alone, but require objective confirmation using urodynamic studies. investigations

4. 1-Mid-stream urine Urinary infections can produce a variety of symptoms include incontinence. MSU is taken for culture& sensitivity with pure growth of more than 10 5 organisms per mL of urine diagnose infection.

5. 2-Urinary diary Simple recording over three days of the daily fluid intake &output with minimal&maximal volume of voids will give a good deal of information about bladder function.

6. 3-Pad test This test used to verify & quantify urine loss The patient wears a pre-weighed sanitary towel,drinks 500 mL of water.After a series of defined manoeuvers the pad is reweighed,urine loss of more than 1 gm is considered significant.

7. 4-Uroflowmetry Measurement of urine flow rate is simple,non invasive index of voiding phase. the patient with a comfortably full bladder &voids in private,over a flowmeter.A normal flow has a bell-shaped curve with maximum flow rate exceeding 15 mL\s for a voided volume of at least 150 ml. By contrast the flow rate of a patient with voiding difficulty is attenuated & the rate never rises above 15 ml\s.

8. 5-Cystometry This is fundamental test of bladder function &measure changes in bladder pressure with changes in bladder volume. With the patient lying supine,pressure recording catheters are placed in the bladder& rectum.the residual urine is removed &the bladder is filled at rate of 100 ml \min.the first sensation of filling & full bladder capacity are noted& when the latter is reached the patient stands up &asked to cough several times to demonstrate any urinary leakage

9. She then sits on uroflowmeter &voids in private.She is asked to interrupt&then restart voiding &the peak flow rate &maximum volume pressure are noted. Parameters of normal bladder function are: 1-residual urine of less than 50 ml. 2-1 st desire to void between 150&200 ml. 3-capacity between 400&600 ml. 4-detrusor pressure rise of less than 15 cm H2O during filling &standing. 5-absence of systolic detrusor contractions 6-no leakage of urine 7-voiding detrusor pressure rise of less than 70 cm water with peak flow rate of more than 15 ml\s for volume over 150 ml.

10. 6-videocystourethrograghy(VCU) If radio-opaque filling medium is used during cystometry,then the lower urinary tract can be visualized by X-ray screening with an image intensifier.

12. 7-ultrasound Is becoming more widely used in urogynaecology. Postmicturition urine residual estimation can be performed without need for urethral catheterization &associated risk of infection. Urethral cysts & diverticula can also be examined using this technique.

13. 8-magnetic resonance imaging MRI produce accurate anatomical picture of pelvic floor & lower urinary tract it has been used to demonstrate compartmental prolapse.

15. Urinary incontinance

16. Urinary incontinance is defined as the involuntary loss of urine that is objectively demonstrable &is a social or hygienic problem.It is increasingly prevalent problem as the aging population expands.It affects individual’s physical,psychological& social well-being &associated with significant reduction in quality of life. The prevalence increases with age with approximately 5% of women between 15&44 years of age being affected rising to 10% of those aged between 45&64 years &approximately 20% of those greater than 65 years.

17. classification It is classified according to pathophysiological concepts rather than the symptoms. The following definitions are commonly used:

18. Stress incontinance is a symptom& sign Means loss of urine on physical effort.It is not a diagnosis. Urgency means sudden desire to void Urge incontinance is an involuntary loss of urine associated with strong desire to void. Overflow incontinance occurs without any detrusor activity when the bladder is overdistended.

19. Frequency is defined as the passing of urine seven or more times a day or being awoken from sleep more than once a night to void.

21. Urethral causes of incontinance Urethral sphincter incompetence (genuine stress incontinance) Detrusor instability or the unstable bladder –this is either neuropathic Or non-neuropathic. Retention with overflow Congenital Miscellaneous Extra urethral causes Congenital fistula

23. Genuine stress incontinance Genuine stress incontinance (GSI) or urethral sphincter incompetence (USI) occurs when the detrusor (bladder) pressure exceeds the maximum urethral pressure in the absence of any detrusor contractions. The urethral sphincter is a complex synergistic mechanism comprising voluntary &involuntary muscle,elastic&collagen together with urethral epithelium.

25. It is situated at the region of bladder neck& proximal two thirds of urethra.The bladder neck is normally maintained within the pelvis by posterior pubourethral ligament,periurethral striated muscle &pubocervical fascia.

27. Aetiology Damage to nerve supply of pelvic floor &urethral sphincter caused by child birth.In addition mechanical trauma to pelvic floor muscle& endopelvic fascia &ligaments occurs as consequence to vaginal delivery. Prolonged second stage,large baby&instrumental delivery cause the most damage.

28. Menopause &associated tissue atrophy also cause weakening of pelvic floor Congenital cause may be inferred as some nulliparous women suffer from incontinance.this may be due to altered connective tissue particularly collagen. Chronic causes such as obesity,chronic cough &constipation that cause increase intraabdominal pressure also cause the problem.

30. symptoms The usual symptom is stress incontinence but frequency,urgency&urge incontinence may be present.there may be feeling of prolapse. Signs On clinical examination the patient may demonstrate incontinence on coughing.a cystourethrocele may present in 50% of cases.

32. Prevention Shortening of the second stage of delivery &reducing traumatic delivery The benefit of hormone replacement therapy have not been substantiated Pelvic floor exercises before or during pregnancy need to be evaluated.

33. Conservative management Physiotherapy is the mainstay of conservative treatment of stress incontinance.the rationale behind pelvic floor education is reinforcement of cortical awareness of levator ani muscles,hypertrophy of existing muscle fibres &general increase in muscle tone&strength. Use of biofeedback techniques as perineometry &weighed cones can improve success rate. Maximal electrical stimulation with a variety of devices has been used.z

34. Surgery For women seeking cure the mainstay of treatment is surgery,its aims are: Restoration of the proximal urethra &bladder neck to the zone of intra-abdominal pressure transmission To increase urethral resistance A combination of both

35. Burch colposuspension This corrects both cystourethrocele &incontinence. By Pfanenstiel incision the paravaginal fascia is sutured on either side of the bladder neck &bladder base to the ipsilateral iliopectineal ligament with 90% success rate. Laparascopic colposuspension for elderly patients with same principles but less success rate.

36. Periurethral bulking Contigen collagen,subcutaneous fat & microparticulate silicon(Macroplastique) have been injected paraurethrally or transurethrally at the level of bladder neck Artificial sphincter Is used when convensional surgery had failed,it is a major procedure only performed in tertiary referral centres.