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what causes uterine prolapse (basic path)
laxity of ligaments: transverse cervical, uterosacral
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what is 1st degree prolapse?
cervix is still within the vagina
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what is 2nd degree prolapse?
cervix is at introits
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what is 3rd degree prolapse?
entire uterus comes out
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what is vault prolapse?
if uterus has been removed, the vault=top of vagina where uterus used to be can prolapse
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what causes bladder/bowel prolapse?
levator ani muscle weakness (floor of pelvis)
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what is cystocele?
bladder prolapse through anterior vaginal wall
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what is rectoceled?
prolapse rectum through posterior vaginal wall
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what is enterocele?
- prolapse of pouch of douglas ie peritoneal cavity into posterior vaginal wall just behind the uterus
- usually contains small bowel
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what are symptoms of prolapse?
- draggging sensation
- lump between legs
- lower back pain
- vaginal discomfort
- painful intercourse
- PCB
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what are symptoms of cystocele?
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what are symptoms of rectocele?
difficulty defaecating
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which age group get prolapse and why?
- post menopausal
- as oestrogen deficiency causes atrophy of pelvic supports and vaginal walls
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what needs to be asked in gynae hx?
hysterectomy?
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what are risk factors for prolapse?
- menopause
- hysterectomy
- vaginal deliveries
- multiparity
- obesity
- chronic cough - smoker
- consipation
- ie last 3 = increased IAP
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what examination needs to be done in suspected prolapse?
sims speculum
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what is conservative Rx of prolapse?
- weight loss
- treat cough - stop smoking
- treat constipation
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what is medical Rx of prolapse?
- pessaries = artificial pelvic floor in vagina - stay behind pubic symphysis
- ring or shelf (more severe)
- change every 3-6 months
- oestrogen therapy for post menopausal - topical or systemic
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what are problems with pessaries?
- pain
- urinary retention
- infeciton
- fall out
- bleeding
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what is surgical Rx if major 3rd degree uterine prolapse?
vaginal hysterectomy
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what is Rx of vaginal vault prolapse? give 2 options and route of each
- sacrospinous colpopexy - suspension of vault to sacrospinous ligament. vaginal route
- sacrocolpopexy - fixation of vault to sacrum using a mesh = abdominal route
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what is Rx of cysto/rectocoele?
- anterior or posterior repair
- may need mesh for support
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what is definition of urinary incontinence?
involuntary loss of urine that causes a social problem
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what are RF for incontinence?
- pregnancy
- vaginal delivery
- prolonged labour
- forceps
- obesity
- age - post menopausal
- previous hysterectomy - predispose to SUI
- diuretics
- coffee, alcohol
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what is cystometry?
- catheter in bladder - measure pressure
- pressure transducer in rectum
- fill
- cough
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how is detrusor pressure calculated?
bladder pressure - abdo pressure
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on cystometry how can you tell between SUI and OAB?
OAB: get involuntary detrusor contractions - so detrusor pressure increases spontaneously, also can be provoked eg by cough
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should all pt with UI have cystometry?
- no until failure of lifestyle, medical Rx
- ie only if planning surgery
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what is conservative Rx for SUI?
- pelvic floor muscle training
- 8 contractions tds
- vaginal cones - held in position by voluntary muscle contraction (increased size to inc strength)
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what is medical Rx for SUI?
- duloxetine SSRI
- but SE gastric headache suicide
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what is the aim of surgical Rx for SUI?
to transmit the raised IAP to bladder neck as well as bladder
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what is surgical Rx for SUI?
- TVT
- TOT
- gold standard: burch colposuspension
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what are risks of TVT? so what needs to be done before surgery
- retention
- bladder perforation
- detrusor instability - so do cystometry to exlcude OAB
- erosion
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what is burch colposuspension?
- bladder neck lifted using sutures
- placed via abdominal incision
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what is main symptom of OAB?
- frequent passage of small vol of urine
- esp at night
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what is conservative Rx for OAB - 2
- reduce caffeine, fluid intake
- bladder training - void by clock. increased intervals
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what is medical Rx for OAB?
- anticholinergics
- SE
- oxybutinin, tolerotine, solifenacin
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after tablets, what can be done for OAB?
- botox A injection into detrusor muscle
- sacral nerve stimulation
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what is risk of botox injection?
- total bladder paralysis
- need for intermittent self catheterisation
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what is surgical Rx of OAB?
clam augmentation ileocystoplasty
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