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