Types of prolapse

Urthrocele Lower anterior

vaginal wall Involving urethra

only

Cystocele Upper anterior

vaginal wall Involving bladder

Urethrocystocele As above with associated prolapse of urethra

Types of prolapse

Apical prolapse Prolapse of the uterus,

cervix and upper vagina

Or of the vault

Enterocele Upper posterior wall

of the vagina Resulting pouch usually

contains loops of small bowel

Rectocele Lower posterior wall of vagina Involving anterior wall of the rectum

Pelvic organ prolapse scoring

system Patient must be:

Standing at rest, straining, traction employed

0 No descent of pelvic organs during straining

1 Leading surface of prolapse does not descend below 1cm above the hymenal ring

2 Ledaing edge of prolapse extends from 1cm above to 1cm below the hymenal ring

3 Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion

4 Vagina completely everted (complete procidentia)

Aetiology of prolapse

Vaginal delivery and pregnancy Mechanical injuries, denervation Large infants Prolonged second stage Instrumental delivery

Increased age

Congenital Ehlers-Danlos

Chronic predisposing factors – increasing intra-abdominal pressure Obesity Chronic cough, constipation, heavy lifting

Iatrogenic Pelvic surgery, hysterectomy

Clinical features

Dragging sensation or lump sensation

Interferes with intercourse if severe

Urinary frequency if cysourethrocele

Stress incontinence

?difficulty defecating – rectocele

What examination would you perform?

Abdominal and bimanual examination

Investigation and management

Pelvic ultrasound

Urodynamic testing

Fitness for surgery

Weight reduction, physiotherapy?

Ring pessary or shelf pessary (more effective for severe prolapse May cause pain, urinary retention

Surgical

Surgical treatment

Uterine prolapse Vaginal hysterectomy but…. 40% then have vaginal vault prolapse…

HYSTEROPEXY Uterus and cervix attached to the sacrum using a non-absorbable mesh

Vaginal vault prolapse Sacrocolpopexy

Fixes vault to sacrum

Complications: mesh erosion, haemorrhage

Sacrospinous fixation (vaginally) Suspends vault to sacrospinous ligament

Vaginal wall prolapse Anterior/posterior repair

Urodynamic incontinence TVT – Tension-free vaginal tape Or, Burch colposuspension Usually at same time as prolapse repair

Disorders of the urinary tract

Urinary stress incontinence

Confirm by urodynamic studies -> Urodynamic stress incontinence

Bladder neck below pelvic floor

During increased intra-abdominal pressure, pelvic floor and urethra unable to compensate

Bladder pressure exceeds urethral pressure

Incontinence results

Examination and Investigation

O/E May reveal cystocele or urethrocele

Leakage with coughing

Palpate abdomen Exclude distented bladder (overflow)

Ix Dipstick – exclude infection

Urodynamic studies

Cystometry – exclude overactive bladder

Management

Encourage weight loss if obese Stop smoking (chronic cough) Reduce excessive fluid intake

Pelvic floor muscle training 8 x daily Vaginal cones

Duloxetine (SNRI) SEs: dyspepsia, dry mouth, dizziness, insomnia, drowsiness

Surgery if conservative and pharmacological failed TVT – tension-free vaginal tape or TOT transobturator

tape (more effective than burch colposuspension)

Overactive bladder

Urgency with or without urge incontinence, usually with frequency or nocturia

Symptoms suggestive of DETRUSOR OVERACTIVITY

Detrusor overactivity during the FILLING STAGE May be spontaneous or provoked e.g. coughing (post-cough) Not all with OAB have detrusor overactivity (and vica versa)

Often idiopathic

Can follow USI (urinary stress incontinence) operations

OAB may be due to involuntary detrusor contractions (detrusor overactivity..) May occur in presence of disease e.g. MS or spinal cord

injury

Investigations

History Urge and urge incontinence

Leak at night or orgasm

Hx of childhood enuresis common

Examination Often normal. ?indicental cystocele

Investigations Urinary diary: caffeinated drinks? Frequent

passage of small amounts of urine

Cystometry: contractions on filling or provocation

Management

Reduce fluid and caffeine intake Bladder training

i – education

ii – timed voiding with systematic delay in voiding

iii – positive reinforcement

Anticholingics(antimuscarinics) e.g. oxybutynin, tolterodine, solifenacin

For nocturia – desmopressin

Botulinium toxin A Blocks neuromuscular transmission

Injected cystoscopically – 10-30 locations, duration 6 months

Complication - retention

Oestrogens Women often develop symptoms after the menopause

Oestrogen reduces urgency, urge incontinence, frequency and nocturia

Mixed USI & Overactive bladder

10% of all incontinence cases

Most bothersome symptom treated first

Acute urinary retention

Unable to pass urine for 12hr or more

Catheterisation produces more urine than the normal bladder capacity

Painful (except when due to epidural anaesthesia)

Due to: childbirth, pelvic masses, neurological disease

Chronic retention and overflow

Urethral obstruction or detrusor inactivity

Pelvic masses and incontinence surgery common causes

Autonomic neuropathis (diabetes)

Rx: intermittent self catheterisation

Painful bladder syndrome and

interstitial cystitis PBS: surprapubic pain related to filling of

bladder Absence of UTI or other obvious

pathology

Interstitial cystitis: PBS plus characteristic cystoscopic changes Rx: bladder training Tricyclic antidepressants analgesics

The menopause

The permanent cessation of menstruation

Median age of 51

Early menopause

Before age 40 – 1% of women

Perimenopause From the first feature of the menopause until

12 months after the LMP

Post-menopause 12 months after LMP

Symptoms

Vasomotor Hot flushes, night sweats(70%)

Urogenital Vaginal atrophy, dyspareunia, itching,

burning, dryness

Frequency, urgency, nocturia, incontinence

Sexual problems – desire

Osteoporosis Osteoporotic fractures

Post menopausal bleeding

Vaginal bleeding occurring at least 12 months after the LMP

Causes Endometrial carcinoma

Cervical carcinoma

Endometrial hyperplasia – atypia and polyps (pre-malignant)

Atrophic vaginitis

Cervitis

Ovarian carcinoma

Cervical polyps

Investigations

Bimanual, Speculum and Abdominal examinations

Cervical smear

Transvaginal sonography If >4mm or multiple bleeds then endometrial

biopsy and hysteroscopy required

Biopsy using pipelle

If malignancy excluded, rx. Atrophic vaginitis with topical oestrogen

Endometrial carcinoma

Most common genital tract cancer

Highest prevalence age 60 15% occur premenopausaly

<1% in women <35

>90% Adenocarcinoma of columnar endometrial glad cells Others – adenosquamous carcinoma

Aetiology High or unopposed oestrogen levels (no progesterone)

Risk factors

Exogenous oestrogens (without progestogen)

Obesity (androgens -> oestrogens)

PCOS

Nulliparity

Late menopause

Tamoxifen

COCP is a PROTECTIVE factor

Investigations

Presentation usually PMB, IMB or irregular bleeding

USS/TVS If endometrium >4mm pipelle or hysteroscopy.

Biopsy required for diagnosis

Staging

1 Uterus only

1A < ½ myometrial invasion

1B > ½ myometrial invasion

2 Cervix involved

3 Pelvic/para-aortic lymph nodes

4 Bowel and bladder or distant spread

Cervical carcinoma

90% Squamous cell carcinoma

Pre-invasive stage – Cervical intraepithelial neoplasia Peak incidence 25-29 years

If untreated approx… 1/3 women with CIN II/III will develop cervical cancer over the next 10 years

Screening – All women

Every 3 years from 25-49

Every 5 years from 50-64

History and examination

Post coital bleeding or PMB

Pain is a late feature

Smear tests often missed

Ulcer or mass may be visible or palpable on the cervix

Diagnosis made by biopsy or LLETZ

Staging

1 Cervix and uterus

1a(i) <3mm depth

1a(ii) <7mm across

1a(iii) <5mm depth

1b rest

2 Upper vagina also

2a Not parametrium

2b In parametrium

3 Lower vagina or pelvic wall or ureteric obstruction

4 Into bladder or rectum, or beyond pelvis

Treatment

Dependant on stage

Surgery or chemo-radiotherapy

Overall, 65% 5 year survival rate

Ovarian Carcinoma

Risk factors relate to number of ovulations Early menarche

Late menopause

Nulliparity

May be familial – BRCA1, BRCA2

Protective factors Pregnancy and lactation

The pill

Presentation

Often vague or absent

Persistent abdominal distention

Pelvic or abdominal pain

Urinary urgency/frequency

IBS symptoms

O/E Cachexia, pelvic mass, ascites

Investigations

CA125 measurement If >35IU/mL -> USS abdomen

Risk of malignancy index calculated (RMI) USS score, menopausal status, CA125

levels

CT pelvis and abdomen

Staging

1 Macroscopically confined to ovaries

2 Beyond ovaries but confined to pelvis

3 Beyond pelvis but confined to abdomen. Omentum and small bowel frequently involved

4 Beyond abdomen. E.g. lungs or liver parenchyma

Management

Surgical Midline laparotomy

Chemotherapy CA125 levels can be used to monitor

response to chemotherapy