Prolapse & Urogynecology

1. Prolapse & Urogynecology Dr:Sa’adeh S . Jaber MBBS, MRCOG,MRCPI Consultant Gynecology &Obstetric Makased Islamic Charitable hospital

2. Pelvic anatomy

4. Risk factors • 􀁹 Vaginal delivery • 􀁹 Age ----- menopause? • 􀁹 Previous prolapsed surgery • 􀁹 Other • 􀁹 Physical stress • 􀁹 Increase intra-abdominal pressure

5. Diagnosis • 􀁹 History taking • 􀁹 Physical examination • 􀁹 Pelvic examination

9. Treatment • 􀁹 Non-surgical treatment Pelvic floor muscle exercise Pessary treatment Support pessaries Space filling pessaries • 􀁹 Surgical treatment

13. Urinary incontinence • Definition :- (ICS) involuntary loss of urine that is objectively demonstrated and is a social or hygienic problem • Incidence :- 10-25% among population 15-64 years of age Up to 45% around age of 70- 80

14. Etiology • 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

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

16. Clinical 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

17. Clinical evaluation (cont) * Physical examination A- Routine Exam nutritional status mental status mobility presence of hernia neurologic exam

18. 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

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

20. Investigation 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

21. 5 - Uroflowmetry does not help in diagnosing type of incontenence , but indicate if any voiding problems with it’s implication

23. Normal voiding

24. Obstructive voiding

25. 6 – Cystometry = Gold Standard = Demonstrate :- capacity, filling phase, storage, detrusor function, Demonstrate :- volume, pressure, contraction relationship Normal :- first sensation ------ 150 ml fullness --------------- 200 – 300 ml maximal capacity--- 400 – 700 ml

26. 7 – Video urodynamics cysto, flowmetry + radiological contrast imaging 8 – Neurological tests EMG asses neuromascular dysfunction integrity of pelvic floor innervation

27. Stress 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

28. Management • Conservative When , Why & For how long Diet modification Kegel’s exercise electrical stimulation biofeed back ring pessaries

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

34. 3) Surgical :- 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%

35. b- Marshall-Marchetti-Krantz urethropexy:- suturing the periurethral tissue to the periosteum of pubic symphysis success rate 75-85 % post operative voiding dysfunction 28% osteitis pubis

37. c- Burch colposuspension :- suturing the periurethral tissue to cooper’s ligament initial success rate ≈ 90-95 % long term success rate 80-90% enterocele 8% DI 10% *modification

43. 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

46. e- TVT

47. 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

49. g- artificial sphincter h- urinary diversion

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